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A community health nurse is triaging clients following a worksite explosion.

Exhibits
Select the 2 clients that the nurse should identify as requiring immediate care.

Client 1

Client 2

Client 3

Client 4

Client 5

Client 6

Answer and Explanation

Correct Answer : D,F

Client 1: This client has a minor laceration with minimal drainage and stable vital signs. No signs of shock or infection are present. This injury is not life-threatening and can wait, making this client a low-priority (green-tag) case.
Client 2: Although this client is experiencing worsening pain and signs of mild hypovolemia, they are alert and have stable vital signs. This client needs prompt care, but not immediate life-saving interventions, making them a delayed (yellow-tag) priority.
Client 3: The client has a mild head injury with stable neurological signs and no evidence of increased intracranial pressure or altered consciousness. This presentation does not require immediate intervention and would also be triaged as delayed.
Client 4: This client presents with signs of severe traumatic brain injury—fixed pupils, decorticate posturing, and irregular respirations—which indicate brainstem dysfunction. Although the prognosis is poor, the condition is immediately life-threatening and requires urgent airway and neurological support, making this client a top priority (red-tag).
Client 5: This client has an open fracture and reports significant pain but has stable vital signs and adequate circulation. The injury requires treatment but is not immediately life-threatening, so they can be managed later (yellow-tag).
Client 6: The client shows signs of progressing respiratory distress—tripod positioning, retractions, anxiety, and diminished breath sounds—indicating possible airway compromise from inhalation injury. This is an urgent, potentially fatal condition requiring immediate airway management (red-tag).

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Correct Answer is ["C","E"]

Explanation

A. A red light kept on in the bedroom at night can provide low-level illumination that helps prevent falls during nighttime bathroom trips. This is generally considered a safe practice and can improve visibility without disrupting sleep significantly.

B. Carpeted floors provide a softer surface that can reduce the risk of injury from falls, especially for older adults. Carpet also helps prevent slipping compared to hard, smooth floors, making it a positive safety feature in the home.

C. A water heater set at 54.4° C (130° F) poses a scalding risk, especially for older adults or clients with decreased sensation. The recommended safe temperature to prevent burns is 49° C (120° F) or lower. The nurse should recommend lowering the temperature to reduce injury risk.

D. A rubber-backed bath mat outside the shower increases traction on wet floors and helps prevent slipping. This is an important safety measure in bathrooms, which are common sites for falls.

E. An extension cord stretched across the floor creates a significant tripping hazard. The nurse should recommend removing or repositioning the cord to eliminate this risk and improve home safety.

A. Primary prevention B. Tertiary prevention C. Screening D. Case findings

Correct Answer is A

Explanation

A. Primary prevention: This strategy aims to prevent the onset of disease or injury before it occurs. By educating adolescents on the dangers of smoking, the nurse is promoting behaviors that reduce the risk of starting tobacco use, thereby preventing potential health issues like cancer or cardiovascular disease.

B. Tertiary prevention: This involves managing and reducing complications in individuals who already have a disease. The nurse is not treating or managing existing health issues related to smoking but is trying to prevent tobacco use entirely.

C. Screening: Screening identifies individuals who may have a disease or risk factor early on. No diagnostic or early detection efforts are involved in this educational session.

D. Case findings: Case finding involves actively identifying individuals with a specific condition, often through outreach or assessment. The nurse is not identifying smokers or tobacco-related illness in this scenario.

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A community health nurse is triaging clients following a worksite explosion. Exhibits Select the 2 clients that the nurse should identify as requiring immediate care.

Nursing Test Bank

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Correct Answer is ["C","E"]

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Correct Answer is A

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A community health nurse is triaging clients following a worksite explosion.

Exhibits
Select the 2 clients that the nurse should identify as requiring immediate care.