the nurse is performing triage on a group of clients in the emergency department which of the following clients should the nurse see first
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2023

1. The nurse is performing triage on a group of clients in the emergency department. Which of the following clients should the nurse see first?

Correct answer: B

Rationale: The correct answer is B. A 19-year-old with a fever of 103.8°F who is confused and unable to orient to place and time likely has a severe infection or a serious medical condition affecting the central nervous system. This client needs immediate attention as altered mental status combined with a high fever can indicate a life-threatening situation. Choices A, C, and D present important conditions that require medical care, but they are not as urgent as the 19-year-old with a high fever and confusion. The 12-year-old with a laceration may require treatment for bleeding and a tetanus shot, the 49-year-old with a compound fracture needs urgent orthopedic intervention, and the 65-year-old with a high blood sugar is concerning for hyperglycemia but can wait momentarily compared to the client with a fever and altered mental status.

2. A healthcare provider is reviewing the medical record of a client who is scheduled for an abdominal paracentesis. Which of the following actions should the healthcare provider take to prepare the client for this procedure?

Correct answer: A

Rationale: Assisting the client to void before a paracentesis is essential to reduce the risk of bladder injury during the procedure. Voiding helps empty the bladder, preventing accidental puncture during the insertion of the needle. Instructing the client to hold their breath is incorrect and can increase the risk of complications. Placing the client in a lateral recumbent position is not directly related to bladder safety during a paracentesis. Preparing to administer a sedative is not a standard preparation for this procedure and is not aimed at preventing bladder injury.

3. A nurse is caring for a client with a pressure ulcer. Which of the following interventions is most appropriate?

Correct answer: D

Rationale: The correct answer is to cleanse the wound from the center outwards. This technique helps prevent infection and promotes healing by ensuring that any contaminants are moved away from the center of the wound. Administering a protein supplement (choice A) or increasing protein intake in the client's diet (choice B) may be beneficial for overall healing but are not the most appropriate interventions specifically for wound care. Increasing IV fluid intake (choice C) is important for hydration but is not the most appropriate intervention for managing a pressure ulcer.

4. A nurse is caring for a client who has diabetes mellitus and is receiving insulin. Which of the following findings should the nurse report to the provider?

Correct answer: B

Rationale: The correct answer is B. A blood glucose level of 200 mg/dL indicates hyperglycemia, which may necessitate insulin adjustment to better control the client's blood sugar levels. A fasting blood glucose of 90 mg/dL (choice A) is within the normal range, a hemoglobin A1c of 6% (choice C) is indicative of good long-term blood sugar control, and a fasting blood glucose of 100 mg/dL (choice D) is also within the normal range. Therefore, these findings do not require immediate reporting to the provider.

5. What are the early signs of diabetic ketoacidosis?

Correct answer: A

Rationale: The correct answer is A: Excessive thirst and fruity breath odor. Diabetic ketoacidosis presents with these early signs due to ketone buildup in the body. Choice B, weight loss and increased urination, are more characteristic of uncontrolled diabetes but not specific to diabetic ketoacidosis. Choice C, nausea and vomiting, can occur in diabetic ketoacidosis but are not as early or specific as excessive thirst and fruity breath odor. Choice D, hypoglycemia and fatigue, are not typical signs of diabetic ketoacidosis; rather, diabetic ketoacidosis usually presents with hyperglycemia.

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