HESI UCA1 D444 Adult I OA 1.
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Free HESI UCA1 D444 Adult I OA 1. Questions
1. The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?
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Prevent esophageal reflux
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Promote effective swallowing
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Maintain intact oral mucosa
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Increase intestinal peristalsis
Explanation
Explanation
Correct Answer: (A) Prevent esophageal reflux
A sliding hiatal hernia occurs when the gastroesophageal junction and a portion of the stomach slide up through the diaphragmatic hiatus into the thoracic cavity. This disrupts the lower esophageal sphincter mechanism, allowing gastric acid to reflux into the esophagus. The primary nursing goal is to prevent esophageal reflux through positioning strategies such as elevating the head of the bed, dietary modifications, avoidance of tight clothing, and administration of prescribed antacids or proton pump inhibitors.
Why Other Options are Incorrect:
B. Promote effective swallowing — Swallowing difficulties are more associated with esophageal strictures, motility disorders, or large paraesophageal hernias. While some discomfort with swallowing may occur, promoting swallowing is not the primary care goal for a sliding hiatal hernia.
C. Maintain intact oral mucosa — Oral mucosa integrity is a concern in conditions such as stomatitis, oral infections, or chemotherapy side effects. It is not a relevant care goal for hiatal hernia management.
D. Increase intestinal peristalsis — Intestinal peristalsis is a concern in conditions such as ileus or constipation. A sliding hiatal hernia affects the upper gastrointestinal tract and the gastroesophageal junction, not intestinal motility.
Correct Answer: (A) Prevent esophageal reflux
A sliding hiatal hernia occurs when the gastroesophageal junction and a portion of the stomach slide up through the diaphragmatic hiatus into the thoracic cavity. This disrupts the lower esophageal sphincter mechanism, allowing gastric acid to reflux into the esophagus. The primary nursing goal is to prevent esophageal reflux through positioning strategies such as elevating the head of the bed, dietary modifications, avoidance of tight clothing, and administration of prescribed antacids or proton pump inhibitors.
Why Other Options are Incorrect:
B. Promote effective swallowing — Swallowing difficulties are more associated with esophageal strictures, motility disorders, or large paraesophageal hernias. While some discomfort with swallowing may occur, promoting swallowing is not the primary care goal for a sliding hiatal hernia.
C. Maintain intact oral mucosa — Oral mucosa integrity is a concern in conditions such as stomatitis, oral infections, or chemotherapy side effects. It is not a relevant care goal for hiatal hernia management.
D. Increase intestinal peristalsis — Intestinal peristalsis is a concern in conditions such as ileus or constipation. A sliding hiatal hernia affects the upper gastrointestinal tract and the gastroesophageal junction, not intestinal motility.
2. A client who was admitted yesterday with bilateral pneumonia has congested breath sounds, an oxygen saturation of 94%, and a temperature of 100°F (37.8°C). The client has a weak cough effort and is using their accessory muscles to breathe. Which intervention should the nurse implement first?
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Offer a prescribed PRN analgesic
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Administer a prescribed antipyretic
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Suction to clear secretions from airway
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Obtain arterial blood gas measurements
Explanation
Explanation
Correct Answer: (C) Suction to clear secretions from airway
The client is demonstrating signs of airway compromise — congested breath sounds, oxygen saturation of 94%, weak cough effort, and use of accessory muscles to breathe. The inability to clear secretions effectively is the most immediate threat to airway patency and oxygenation. Suctioning to remove accumulated secretions is the priority intervention using the ABC framework, as maintaining a patent airway takes precedence over all other actions.
Why the other options are incorrect:
A. Offer a prescribed PRN analgesic — Pain management is not the priority in this situation. There is no indication that pain is contributing to the client's respiratory distress, and administering an analgesic does not address the immediate airway and oxygenation concerns.
B. Administer a prescribed antipyretic — While the client has a low-grade fever of 100°F, this is not the most urgent concern. The fever does not pose an immediate threat comparable to the compromised airway and declining oxygen saturation.
D. Obtain arterial blood gas measurements — ABG measurement provides important data about oxygenation and acid-base status, but it is an assessment action rather than a direct intervention. Clearing the airway takes priority before obtaining diagnostic data.
Correct Answer: (C) Suction to clear secretions from airway
The client is demonstrating signs of airway compromise — congested breath sounds, oxygen saturation of 94%, weak cough effort, and use of accessory muscles to breathe. The inability to clear secretions effectively is the most immediate threat to airway patency and oxygenation. Suctioning to remove accumulated secretions is the priority intervention using the ABC framework, as maintaining a patent airway takes precedence over all other actions.
Why the other options are incorrect:
A. Offer a prescribed PRN analgesic — Pain management is not the priority in this situation. There is no indication that pain is contributing to the client's respiratory distress, and administering an analgesic does not address the immediate airway and oxygenation concerns.
B. Administer a prescribed antipyretic — While the client has a low-grade fever of 100°F, this is not the most urgent concern. The fever does not pose an immediate threat comparable to the compromised airway and declining oxygen saturation.
D. Obtain arterial blood gas measurements — ABG measurement provides important data about oxygenation and acid-base status, but it is an assessment action rather than a direct intervention. Clearing the airway takes priority before obtaining diagnostic data.
3. A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?
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Anorexia
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Clay colored stool
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Brown, foamy urine
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Hematemesis
Explanation
Explanation
Correct Answer: (D) Hematemesis
Esophageal varices are dilated, fragile veins in the esophagus that develop due to portal hypertension in cirrhosis. These vessels are prone to spontaneous rupture, causing sudden, massive upper gastrointestinal bleeding. Hematemesis — vomiting of blood — is the hallmark sign of variceal rupture and represents a life-threatening emergency requiring immediate intervention. It is the most critical complication to monitor for in this client.
Why Other Options are Incorrect:
A. Anorexia — Loss of appetite is a common chronic symptom of cirrhosis and liver disease in general, but it does not represent an acute life-threatening complication of esophageal varices specifically.
B. Clay colored stool — Pale or clay-colored stool indicates absence of bile in the stool, associated with biliary obstruction or liver disease. While relevant to cirrhosis overall, it is not the most urgent monitoring priority related to esophageal varices.
C. Brown, foamy urine — Dark or foamy urine can indicate bilirubin in the urine, a sign of liver dysfunction. It is a chronic finding in cirrhosis but not the acute life-threatening complication most associated with esophageal varices.
Correct Answer: (D) Hematemesis
Esophageal varices are dilated, fragile veins in the esophagus that develop due to portal hypertension in cirrhosis. These vessels are prone to spontaneous rupture, causing sudden, massive upper gastrointestinal bleeding. Hematemesis — vomiting of blood — is the hallmark sign of variceal rupture and represents a life-threatening emergency requiring immediate intervention. It is the most critical complication to monitor for in this client.
Why Other Options are Incorrect:
A. Anorexia — Loss of appetite is a common chronic symptom of cirrhosis and liver disease in general, but it does not represent an acute life-threatening complication of esophageal varices specifically.
B. Clay colored stool — Pale or clay-colored stool indicates absence of bile in the stool, associated with biliary obstruction or liver disease. While relevant to cirrhosis overall, it is not the most urgent monitoring priority related to esophageal varices.
C. Brown, foamy urine — Dark or foamy urine can indicate bilirubin in the urine, a sign of liver dysfunction. It is a chronic finding in cirrhosis but not the acute life-threatening complication most associated with esophageal varices.
4. Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?
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Review food labels for sodium content
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Monitor daily urine output volume
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Use salt tablets after strenuous exercise
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Drink plenty of water whenever thirsty
Explanation
Explanation
Hypernatremia is characterized by elevated serum sodium levels above 145 mEq/L. A key component of discharge teaching is helping the client identify and limit dietary sodium intake. Reading food labels allows the client to make informed choices and avoid hidden sodium in processed and packaged foods, directly addressing the cause of hypernatremia and preventing recurrence.
Why the other options are incorrect:
B. Monitor daily urine output volume — While monitoring urine output can be useful in certain fluid and electrolyte imbalances, it is not the primary discharge teaching priority for hypernatremia. The focus should be on sodium restriction and adequate fluid intake.
C. Use salt tablets after strenuous exercise — Salt tablets would increase sodium intake and directly worsen hypernatremia. This instruction is contraindicated for a client with elevated sodium levels.
D. Drink plenty of water whenever thirsty — While adequate hydration is important, relying solely on thirst as a guide is not sufficient for managing hypernatremia. Older adults in particular may have a diminished thirst response. The client needs structured guidance on both fluid intake and sodium restriction, not a general thirst-based approach.
Hypernatremia is characterized by elevated serum sodium levels above 145 mEq/L. A key component of discharge teaching is helping the client identify and limit dietary sodium intake. Reading food labels allows the client to make informed choices and avoid hidden sodium in processed and packaged foods, directly addressing the cause of hypernatremia and preventing recurrence.
Why the other options are incorrect:
B. Monitor daily urine output volume — While monitoring urine output can be useful in certain fluid and electrolyte imbalances, it is not the primary discharge teaching priority for hypernatremia. The focus should be on sodium restriction and adequate fluid intake.
C. Use salt tablets after strenuous exercise — Salt tablets would increase sodium intake and directly worsen hypernatremia. This instruction is contraindicated for a client with elevated sodium levels.
D. Drink plenty of water whenever thirsty — While adequate hydration is important, relying solely on thirst as a guide is not sufficient for managing hypernatremia. Older adults in particular may have a diminished thirst response. The client needs structured guidance on both fluid intake and sodium restriction, not a general thirst-based approach.
5. Which information should the nurse include in preoperative teaching for a client with a retinal tear?
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Wear an eye patch to enhance rapid eye movement
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Lift objects that weigh less than 25 pounds (11 kg)
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Avoid reading until the postoperative appointment
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Instill eye drops to promote pupillary constriction
Explanation
Explanation
Correct Answer: (C) Avoid reading until the postoperative appointment
Reading requires repeated, rapid eye movements that increase strain and movement of the injured retina. In the preoperative period following a retinal tear, avoiding reading reduces the risk of extending the tear or causing further retinal detachment before surgical repair. This is a key instruction to include in preoperative teaching to protect vision and prevent worsening of the injury.
Why the other options are incorrect:
A. Wear an eye patch to enhance rapid eye movement — An eye patch is used to restrict eye movement and protect the eye, not to enhance rapid eye movement. Promoting rapid eye movement would worsen a retinal tear by increasing traction on the damaged tissue.
B. Lift objects that weigh less than 25 pounds (11 kg) — Lifting any significant weight increases intraocular pressure and Valsalva strain, which can worsen a retinal tear or precipitate detachment. The preoperative recommendation is typically to avoid heavy lifting entirely, not to set a specific weight limit of 25 pounds.
D. Instill eye drops to promote pupillary constriction — Preoperative management of retinal tears typically involves mydriatic drops to dilate the pupil, allowing better visualization of the retina for examination and surgical planning. Drops that cause pupillary constriction would impair visualization and are not appropriate preoperatively.
Correct Answer: (C) Avoid reading until the postoperative appointment
Reading requires repeated, rapid eye movements that increase strain and movement of the injured retina. In the preoperative period following a retinal tear, avoiding reading reduces the risk of extending the tear or causing further retinal detachment before surgical repair. This is a key instruction to include in preoperative teaching to protect vision and prevent worsening of the injury.
Why the other options are incorrect:
A. Wear an eye patch to enhance rapid eye movement — An eye patch is used to restrict eye movement and protect the eye, not to enhance rapid eye movement. Promoting rapid eye movement would worsen a retinal tear by increasing traction on the damaged tissue.
B. Lift objects that weigh less than 25 pounds (11 kg) — Lifting any significant weight increases intraocular pressure and Valsalva strain, which can worsen a retinal tear or precipitate detachment. The preoperative recommendation is typically to avoid heavy lifting entirely, not to set a specific weight limit of 25 pounds.
D. Instill eye drops to promote pupillary constriction — Preoperative management of retinal tears typically involves mydriatic drops to dilate the pupil, allowing better visualization of the retina for examination and surgical planning. Drops that cause pupillary constriction would impair visualization and are not appropriate preoperatively.
6. An adult client is admitted with AIDS and oral candidiasis manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide the UAP?
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Assist with personal care, but leave oral care for the nurse to complete
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Wear sterile gloves when cleansing any areas of infected mucosa
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Provide a soft bristled toothbrush for the client to use during oral care
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Offer the client mouthwash for thorough cleansing after brushing teeth
Explanation
Explanation
A soft bristled toothbrush minimizes trauma and irritation to the already painful and ulcerated oral mucosa associated with oral candidiasis. Gentle oral hygiene is essential in immunocompromised clients with mouth ulcers to maintain cleanliness without worsening tissue damage. This is a safe and appropriate task to delegate to the UAP with clear instruction.
Why the other options are incorrect:
A. Assist with personal care, but leave oral care for the nurse to complete — Oral care in a client with oral candidiasis is within the scope of a UAP when properly instructed by the nurse. There is no clinical reason that requires the nurse to exclusively perform this task.
B. Wear sterile gloves when cleansing any areas of infected mucosa — Standard precautions with clean gloves are appropriate for oral care. Sterile gloves are reserved for invasive procedures involving sterile body cavities. Using sterile gloves for oral care is unnecessary and not standard practice.
D. Offer the client mouthwash for thorough cleansing after brushing teeth — Commercial mouthwashes often contain alcohol, which can further irritate and dry out already painful oral ulcers. Alcohol-based mouthwash is contraindicated in clients with oral mucositis or candidiasis.
A soft bristled toothbrush minimizes trauma and irritation to the already painful and ulcerated oral mucosa associated with oral candidiasis. Gentle oral hygiene is essential in immunocompromised clients with mouth ulcers to maintain cleanliness without worsening tissue damage. This is a safe and appropriate task to delegate to the UAP with clear instruction.
Why the other options are incorrect:
A. Assist with personal care, but leave oral care for the nurse to complete — Oral care in a client with oral candidiasis is within the scope of a UAP when properly instructed by the nurse. There is no clinical reason that requires the nurse to exclusively perform this task.
B. Wear sterile gloves when cleansing any areas of infected mucosa — Standard precautions with clean gloves are appropriate for oral care. Sterile gloves are reserved for invasive procedures involving sterile body cavities. Using sterile gloves for oral care is unnecessary and not standard practice.
D. Offer the client mouthwash for thorough cleansing after brushing teeth — Commercial mouthwashes often contain alcohol, which can further irritate and dry out already painful oral ulcers. Alcohol-based mouthwash is contraindicated in clients with oral mucositis or candidiasis.
7. The nurse should include which information in the teaching plan for a client recently diagnosed with primary open-angle glaucoma? Select all that apply.
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Regular eye exams are necessary to monitor intraocular pressure (IOP) and visual fields
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Intermittent vision loss affecting central vision to peripheral vision
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Vigorous exercise such as jogging or running should be avoided
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Limit salt intake to reduce increased intraocular pressure (IOP)
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Daily eye medications are instilled to lower intraocular pressure (IOP)
Explanation
Explanation
Regular eye exams are necessary to monitor intraocular pressure and visual fields — Ongoing monitoring is essential in glaucoma management because the condition is chronic and progressive. Regular examinations allow the provider to assess disease progression, evaluate treatment effectiveness, and adjust therapy as needed to prevent irreversible vision loss.
Daily eye medications are instilled to lower intraocular pressure — The primary treatment for primary open-angle glaucoma is the use of topical eye drops to reduce IOP. These medications must be used consistently every day as prescribed to maintain adequate pressure control and prevent optic nerve damage.
Why Other Options are Incorrect:
B. Intermittent vision loss affecting central vision to peripheral vision — This description is characteristic of macular degeneration, not glaucoma. Primary open-angle glaucoma causes gradual peripheral vision loss first, progressing toward central vision, and is often asymptomatic in early stages. It does not cause intermittent vision loss.
C. Vigorous exercise such as jogging or running should be avoided — Moderate aerobic exercise, including jogging, has actually been shown to lower IOP and is generally recommended for glaucoma patients. There is no standard clinical guideline advising avoidance of vigorous exercise in primary open-angle glaucoma.
D. Limit salt intake to reduce increased intraocular pressure — Dietary sodium restriction is not an established evidence-based intervention for managing IOP in primary open-angle glaucoma. Salt restriction is relevant to cardiovascular and renal conditions, not glaucoma management.
Regular eye exams are necessary to monitor intraocular pressure and visual fields — Ongoing monitoring is essential in glaucoma management because the condition is chronic and progressive. Regular examinations allow the provider to assess disease progression, evaluate treatment effectiveness, and adjust therapy as needed to prevent irreversible vision loss.
Daily eye medications are instilled to lower intraocular pressure — The primary treatment for primary open-angle glaucoma is the use of topical eye drops to reduce IOP. These medications must be used consistently every day as prescribed to maintain adequate pressure control and prevent optic nerve damage.
Why Other Options are Incorrect:
B. Intermittent vision loss affecting central vision to peripheral vision — This description is characteristic of macular degeneration, not glaucoma. Primary open-angle glaucoma causes gradual peripheral vision loss first, progressing toward central vision, and is often asymptomatic in early stages. It does not cause intermittent vision loss.
C. Vigorous exercise such as jogging or running should be avoided — Moderate aerobic exercise, including jogging, has actually been shown to lower IOP and is generally recommended for glaucoma patients. There is no standard clinical guideline advising avoidance of vigorous exercise in primary open-angle glaucoma.
D. Limit salt intake to reduce increased intraocular pressure — Dietary sodium restriction is not an established evidence-based intervention for managing IOP in primary open-angle glaucoma. Salt restriction is relevant to cardiovascular and renal conditions, not glaucoma management.
8. Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant?
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Administer a stool softener.
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Observe pupil response of the right eye.
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Turn, cough, and deep breathe every 2 hours.
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Sleep flat in a supine position.
Explanation
Explanation
Correct Answer: (A) Administer a stool softener.
Following cataract extraction with a lens implant, it is critical to prevent any sudden increase in intraocular pressure (IOP). Straining during a bowel movement significantly raises IOP, which can disrupt the surgical site and compromise the lens implant. Administering a stool softener prevents constipation and straining, making it the most important discharge instruction to include.
Why the other options are incorrect:
B. Observe pupil response of the right eye — Post-operatively, the nurse should monitor the operative left eye, not the unaffected right eye. Observing the wrong eye provides no clinically useful information regarding surgical recovery.
C. Turn, cough, and deep breathe every 2 hours — This is a standard post-operative instruction for abdominal or thoracic surgeries to prevent pulmonary complications. Coughing, however, dramatically increases intraocular pressure and is actually contraindicated following eye surgery.
D. Sleep flat in a supine position — Clients following cataract surgery are typically instructed to sleep with the head of the bed elevated and to avoid lying on the operative side, not flat. Sleeping flat can increase IOP and increase the risk of complications.
Correct Answer: (A) Administer a stool softener.
Following cataract extraction with a lens implant, it is critical to prevent any sudden increase in intraocular pressure (IOP). Straining during a bowel movement significantly raises IOP, which can disrupt the surgical site and compromise the lens implant. Administering a stool softener prevents constipation and straining, making it the most important discharge instruction to include.
Why the other options are incorrect:
B. Observe pupil response of the right eye — Post-operatively, the nurse should monitor the operative left eye, not the unaffected right eye. Observing the wrong eye provides no clinically useful information regarding surgical recovery.
C. Turn, cough, and deep breathe every 2 hours — This is a standard post-operative instruction for abdominal or thoracic surgeries to prevent pulmonary complications. Coughing, however, dramatically increases intraocular pressure and is actually contraindicated following eye surgery.
D. Sleep flat in a supine position — Clients following cataract surgery are typically instructed to sleep with the head of the bed elevated and to avoid lying on the operative side, not flat. Sleeping flat can increase IOP and increase the risk of complications.
9. A low-residue diet is prescribed for a client with ulcerative colitis who has blood in stool. Which breakfast selection(s) should the nurse include in this client's diet teaching plan? Select all that apply.
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Toasted white bread with margarine
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Scrambled eggs
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Fresh squeezed orange juice
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Oatmeal with raisins and slivered walnuts
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Pancakes with maple syrup
Explanation
Explanation
A low-residue diet limits foods that increase bowel activity and stool bulk in order to reduce irritation of the inflamed colon. Toasted white bread with margarine is made from refined grains that are low in fiber and easy to digest. Scrambled eggs are an excellent low-residue protein source that is gentle on the gastrointestinal tract. Pancakes with maple syrup, made from refined flour with no added seeds, nuts, or whole grains, are also appropriate for a low-residue diet.
Why the other options are incorrect:
C. Fresh squeezed orange juice — While juice may seem light, fresh squeezed orange juice contains pulp and can be irritating to an inflamed colon. Strained or pulp-free juice would be acceptable, but fresh squeezed with pulp is not appropriate for a low-residue diet.
D. Oatmeal with raisins and slivered walnuts — Oatmeal is a high-fiber food, and raisins and walnuts add additional fiber and residue. This combination is contraindicated on a low-residue diet as it would increase stool bulk and potentially worsen symptoms in a client with active ulcerative colitis.
A low-residue diet limits foods that increase bowel activity and stool bulk in order to reduce irritation of the inflamed colon. Toasted white bread with margarine is made from refined grains that are low in fiber and easy to digest. Scrambled eggs are an excellent low-residue protein source that is gentle on the gastrointestinal tract. Pancakes with maple syrup, made from refined flour with no added seeds, nuts, or whole grains, are also appropriate for a low-residue diet.
Why the other options are incorrect:
C. Fresh squeezed orange juice — While juice may seem light, fresh squeezed orange juice contains pulp and can be irritating to an inflamed colon. Strained or pulp-free juice would be acceptable, but fresh squeezed with pulp is not appropriate for a low-residue diet.
D. Oatmeal with raisins and slivered walnuts — Oatmeal is a high-fiber food, and raisins and walnuts add additional fiber and residue. This combination is contraindicated on a low-residue diet as it would increase stool bulk and potentially worsen symptoms in a client with active ulcerative colitis.
10. A client presents to the emergency department (ED) with muscle aches, headache, fever, and describes a recent loss of taste and smell. The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?
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Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus
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Report the COVID-19 result to the local health department according to Centers for Disease Control and Prevention (CDC) guidelines
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Counsel family members to monitor for illness symptoms for 2 weeks after last contact with patient
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Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE)
Explanation
Explanation
Correct Answer: (D) Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE)
The most important immediate nursing action is to isolate the client to prevent transmission of the highly contagious COVID-19 virus. Loss of taste and smell combined with the other symptoms strongly suggests COVID-19. Isolation protects other patients, visitors, and healthcare staff who are not wearing appropriate PPE from exposure while testing is pending. Preventing spread takes priority over all other actions at this moment.
Why Other Options are Incorrect:
A. Teach the client to wear a mask, hand wash, and social distance — While important for community prevention, patient education is not the most urgent priority when the client is already in the emergency department. Immediate isolation takes precedence over teaching.
B. Report the COVID-19 result to the local health department — Reporting is a legal and public health obligation but occurs after a confirmed positive result is obtained. The test has not yet returned a result, making this a later-priority action.
C. Counsel family members to monitor for illness symptoms for 2 weeks — Contact tracing and family counseling are important follow-up steps but are not the immediate priority when the client is actively presenting with symptoms in a busy emergency department.
Correct Answer: (D) Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE)
The most important immediate nursing action is to isolate the client to prevent transmission of the highly contagious COVID-19 virus. Loss of taste and smell combined with the other symptoms strongly suggests COVID-19. Isolation protects other patients, visitors, and healthcare staff who are not wearing appropriate PPE from exposure while testing is pending. Preventing spread takes priority over all other actions at this moment.
Why Other Options are Incorrect:
A. Teach the client to wear a mask, hand wash, and social distance — While important for community prevention, patient education is not the most urgent priority when the client is already in the emergency department. Immediate isolation takes precedence over teaching.
B. Report the COVID-19 result to the local health department — Reporting is a legal and public health obligation but occurs after a confirmed positive result is obtained. The test has not yet returned a result, making this a later-priority action.
C. Counsel family members to monitor for illness symptoms for 2 weeks — Contact tracing and family counseling are important follow-up steps but are not the immediate priority when the client is actively presenting with symptoms in a busy emergency department.
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