• NCLEX Pretest
  • Time Used 0:00:00

The nurse receives report on 4 patients by 0800. Which patient does the nurse assess first?

Incorrect

  • Patient with asthma who exhibits audible wheezing and can only speak in short sentences
  • Patient with a complete transverse fracture of the femur who calls out to report difficulty breathing
  • Elderly patient with urinary tract infection and stage III sacral pressure injury who calls out to report an episode of urinary incontinence
  • Patient with a suspected cerebral aneurysm scheduled for a computed tomography scan at 0830 who reports pain and coolness at the IV insertion site

Rationale

The patient who experienced a complete transverse fracture of the femur is at risk for a fat embolism, which can become lodged in the lungs, causing severe dyspnea and feeling of impending doom. This condition is life-threatening; therefore, the nurse should assess this patient first. The patient with asthma who exhibits audible wheezing and can only speak in short sentences is less acute because the patient can still speak; this patient can be seen after the patient with pulmonary embolism. Although the patient with a UTI who had an episode of urinary incontinence should be promptly cleaned and dried to prevent contamination of the pressure injury, this is less life-threatening than a pulmonary embolism. The patient who is scheduled for a CT scan in a half hour and requires a new IV prior to the procedure is not in danger like the patient with a pulmonary embolism.

  • Category: Management of Care
  • Difficulty: 10
  • Tags: Cardiovascular Delegation, Prioritization and Leadership Musculoskeletal Respiratory

Question 4 of 30

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