The student nurse completes a clinical rotation in the emergency department. The instructor knows the student is able to prioritize care appropriately when the student visits which client first?

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11ecbb05_cbe0_cab2_b433_95b5e24bb4ac_MD0009_00 Swelling of the neck and increased pain after a thyroidectomy may indicate hematoma formation or increased tissue inflammation. These complications have a high priority due to potential interference with airway patency. The nurse should assess for signs and symptoms of airway compromise (eg, stridor, use of accessory muscles, restlessness). Suction equipment should be available to clear the airway of secretions, and a tracheostomy tray should be at the bedside in case an emergency tracheotomy is required. (Option A) Bruising, edema, and pain in the ankle following a popping sound indicate a possible sprain. The client should have an x-ray, receive pain medication (eg, nonsteroidal anti-inflammatory drugs), and have the ankle iced and immobilized; however, this client is the lowest priority. (Option C) Blood glucose of 423 mg/dL (23.5 mmol/L), dehydration, and ketonuria indicate possible diabetic ketoacidosis. This client needs an IV fluid bolus, insulin, and likely electrolyte replacement following additional diagnostic testing. This client has potentially compromised circulation and should be seen second. (Option D) Acute altered mental status in an elderly client may indicate infection (eg, urinary tract). Diagnostic testing is needed to identify the source of the altered mental status; however, airway complications and circulatory compromise have a higher priority. This client should be seen third. Educational objective: Clients with possible airway obstruction, respiratory distress, or compromised circulation take priority for assessment and intervention. Neck swelling and increasing pain after a thyroidectomy can indicate hematoma formation or increased tissue inflammation that could lead to airway obstruction.

The Student Nurse Completes a Clinical Rotation in the Emergency