145.

The nurse is caring for client in the Emergency Department of an acute

care facility. Four clients have been admitted in the last 10 minutes. Which
of the following admissions should the nurse see FIRST?
1.
2.
3.
4.

A
A
A
A

client
client
client
client

complaining of chest pain that is unrelieved by nitroglycerine.

with third-degree burns to the face.
with a fractured hip.
complaining of epigastric pain.

Strategy: Think ABCs.

(1) not the highest priority; airway most important
(2) correctface, neck, chest, or abdominal burns result in severe edema, causing
airway restriction
(3) airway is most important
(4) requires further assessment, airway is a priority
146. The nurse is preparing to perform peritoneal dialysis on a 65-year-old
patient. The patient states she had pain the last time the procedure was
done. It would be MOST appropriate for the nurse to take which of the
following actions?
1.
2.
3.
4.

Administer a warm drink to the patient.

Administer a warm bath to the patient.
Warm the bag of dialysate solution with a heating pad.
Warm the bag of dialysate solution in a microwave oven.

Strategy: All answers are implementations. Determine the outcome of each

answer choice. Is it desired?
(1) does not affect pain with fluid infusion
(2) does not affect pain with fluid infusion
(3) correcttemperature can be regulated, warming reduces pain caused by cold
solution
(4) contraindicated because of unpredictable warming patterns
147. Which of the following symptoms are MOST likely to be observed by
the nurse when a client is withdrawing from heroin?
1.
2.
3.
4.

Severe cravings, depression, fatigue, hypersomnia.

Depression, disturbed sleep, restlessness, disorientation.
Nausea and vomiting, tachycardia, coarse tremors, seizures.
Runny nose, yawning, fever, muscle and joint pain, diarrhea.

Strategy: Think about the cause of each symptom and how it relates to
narcotic withdrawal.
(1) describes cocaine withdrawal
(2) describes amphetamine withdrawal
(3) describes barbiturate withdrawal
(4) correctnarcotic withdrawal is very much like the symptoms of the flu