A first-response team is working at the location of a bombing incident. A nurse triaging a group of clients should give treatment priority to which of the following clients?
A client who has a rigid abdomen with manifestations of shock
A client who has a femur fracture with a 2+ pedal pulse
A client who has superficial partial-thickness burn injuries over 5% of his body
A client who is ambulatory and exhibits manic behavior
The Correct Answer is A
The correct answer is choice A. A client who has a rigid abdomen with manifestations of shock should receive treatment priority in this situation. In a bombing incident, clients with life-threatening injuries, such as those with uncontrolled bleeding, airway compromise, or shock, should receive immediate attention. A rigid abdomen may indicate internal bleeding, which is a medical emergency requiring prompt intervention. Manifestations of shock, such as tachycardia, hypotension, and altered level of consciousness, indicate poor tissue perfusion and require immediate intervention. The other clients described in the question have less severe injuries and can wait for treatment while more critical injuries are addressed first. A femur fracture with a 2+ pedal pulse indicates adequate circulation to the extremity, superficial partial-thickness burn injuries over 5% of the body are not life-threatening, and an ambulatory client with manic behavior does not have immediate medical needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C, "An increase in client falls at home." A quality improvement committee is responsible for identifying and addressing areas in need of improvement in client care. Among home health clients, falls are a common cause of injury, which can lead to hospitalizations or even death. Therefore, it is essential to address this issue by examining the data and identifying trends to establish interventions to prevent falls. The committee can evaluate whether proper assessments have been completed, including a home safety evaluation, medication review, and the use of mobility aids, to prevent falls. The committee can also review the use of interventions, such as physical therapy or occupational therapy, to improve mobility and strength, and education for clients, caregivers, and family members to promote safety in the home environment. By addressing the increase in client falls, the committee can improve the quality of care provided to home health clients and reduce the risk of falls and injuries.
Correct Answer is D
Explanation
Children with leukemia are at risk for developing oral mucositis, which is inflammation and ulceration of the oral mucosa due to the destruction of rapidly dividing cells by chemotherapy. Inspecting the child's mouth for sores and providing appropriate mouth care is essential to prevent infection and to maintain hydration and nutrition. Riding a bicycle is not recommended for a child with leukemia because of the risk of falls and injuries, and the measles, mumps, and rubella vaccine is contraindicated for children with leukemia who are receiving chemotherapy. Measuring the temperature orally or axillary is a safe and accurate method for monitoring the child's temperature.
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