The emergency department nurse is assigned to triage. Which client should the nurse assess first?

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11ecbb05_cbc2_6d2f_b433_d7aad408a676_MD0009_00 Life-threatening physiological problems (eg, airway, breathing, circulation) are the highest priority followed by less threatening problems (eg, pain, potential for infection). Unilateral edema and calf pain could be signs of a deep venous thrombosis (DVT), a high-priority circulation problem in which a lower-extremity clot may dislodge, travel, and cause life-threatening complications (eg, pulmonary embolism). Prolonged immobilization (eg, airplane travel, bed rest) increases the risk for DVT. pulmonary embolism (Option A) A client with leg pain during activity that is relieved by rest may have intermittent claudication, a classic sign of peripheral artery disease. This condition is not an immediate threat to survival. (Option B) The client with diabetes has a preexisting medical condition. Physiologic stress related to elevated temperature and possible infection would most likely increase serum glucose level. Although infection in a client with diabetes can present a risk to survival, it is not immediate at this time. (Option D) The client with a dog bite will need antibiotics and possibly a rabies vaccination, but there is no immediate threat to survival. Educational objective: Unilateral lower-extremity edema and calf pain in a client who has recently been immobile for a prolonged period (eg, bed rest, long flight) may indicate the presence of a deep venous thrombosis (DVT). A DVT is a high-priority circulation problem as the clot can dislodge, travel, and cause life-threatening complications (eg, pulmonary embolism).

The Emergency Department Nurse Is Assigned to Triage