Four clients enter the emergency department at the same time. Which should the triage nurse see first?

Question

Quizplus · Accepted Answer

An ECG should be performed immediately on all adult clients with chest pain; all chest pain should be considered cardiac until proven otherwise. After the initial ECG, the client with chest pain will need to be placed on a cardiac monitor and assessed by the health care provider before the other 3 clients. (Option B) This client will need a prescription renewal. Glargine (Lantus) is given once a day, typically in the evening, as basal insulin. The consequence of late administration is hyperglycemia. A single temporary rise in glucose will not have a significant negative impact. The damage to vessels in a diabetic client comes from long-term uncontrolled diabetes. The other clients are a higher priority. (Option C) This client may have a deep vein thrombosis and will probably require anticoagulant therapy. However, this client is hemodynamically stable without evidence of active pulmonary embolism and can safely wait to be seen after the higher-risk client with chest pain. (Option D) This client may have acute diverticulitis and should be seen urgently, but after the client with chest pain. Prioritization should be based on which client is most ill and not on advanced age. Educational objective: Chest pain in an adult, regardless of age, is a priority. It is important to not make assumptions based on client age, race, or nationality.

Four Clients Enter the Emergency Department at the Same Time