A nurse in an emergency department is admitting clients following an earthquake. The emergency disaster plan has been implemented due to the anticipated arrival of a large number of casualties. Which of the following clients should the nurse recommend the provider evaluate first?
A client who has a penetrating head injury and respiratory rate of 4/min.
A client who has a comminuted fracture of the femur.
A client who has a 15.2-cm (6-in) laceration to the scalp with clotted blood visible.
A client who has a sucking chest wound.
The Correct Answer is D
Choice A rationale:
A client who has a penetrating head injury and a respiratory rate of 4/min requires immediate attention due to the critical nature of the head injury and the dangerously low respiratory rate. However, in an emergency situation like this, the priority would be a condition that could be rapidly fatal if not addressed promptly.
Choice B rationale:
A client with a comminuted fracture of the femur has a serious injury that requires assessment and treatment, but it is not an immediately life-threatening condition. It falls lower in the priority compared to conditions that directly impact respiratory and cardiovascular function.
Choice C rationale:
A client with a 15.2-cm laceration to the scalp with clotted blood visible also requires attention, but it is not as time-sensitive as a life-threatening condition. Controlling bleeding and cleaning the wound can be addressed after addressing more critical cases.
Choice D rationale:
Correct. A client with a sucking chest wound has a high risk of tension pneumothorax, a condition where air accumulates in the pleural space, leading to lung collapse and compromised circulation. This condition can be rapidly fatal. Immediate intervention is required to seal the wound and prevent further air from entering the pleural space.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The age of the client might impact the care plan, but it doesn't directly relate to the cost effectiveness of care. Older patients might have different health considerations, but the length of their stay and the services they require play a more significant role in cost evaluation.
Choice B rationale:
While the availability of community support groups can be beneficial for the client's overall well-being and recovery, it doesn't directly contribute to evaluating the cost effectiveness of care. Community support groups are more about psychosocial support than cost.
Choice C rationale:
This is the correct choice. The length of the client's stay directly affects the cost of care. Longer stays often involve more resources, medications, treatments, and staff time, leading to higher costs. Shorter and more efficient stays are generally more cost-effective.
Choice D rationale:
The type of insurance the client carries is relevant to the client's financial responsibility for their care, but it doesn't assist in evaluating the overall cost effectiveness of care. The insurance type might affect reimbursement rates, but it doesn't provide a comprehensive picture of cost efficiency.
Correct Answer is C
Explanation
The correct answer isChoice C.
Choice A rationale:
Instructing a client on how to take their blood pressure is a task that involves providing education to the client on a non-invasive procedure that they can perform independently. However, this task requires a certain level of knowledge and understanding that an assistive personnel (AP) may not possess. Therefore, it is not the best task to delegate to an AP.
Choice B rationale:
Administering subcutaneous medications to a client is a task that requires a high level of skill and knowledge. It involves understanding the medication, its side effects, and the correct administration technique. This is a task that should be performed by a nurse or a healthcare professional with the appropriate training and licensure. Delegating this task to an AP could potentially put the client’s health at risk.
Choice C rationale:
Determining a client’s intake and output is a task that can be delegated to an AP.This task does not require the use of the nursing process and is within the range of function of an AP. It involves measuring and recording the amount of fluid a client consumes and excretes, which is a task that an AP is capable of performing.
Choice D rationale:
Providing a status update to a client’s family member is a task that requires a high level of discretion and understanding of the client’s condition. It involves communicating sensitive information about the client’s health status, which should be done by a nurse or a healthcare professional with the appropriate training and licensure. Delegating this task to an AP could potentially lead to miscommunication or a breach of the client’s privacy.
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