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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Informing the client of the consequences of decreased cerebral circulation is premature without understanding the client's specific reasons for refusing the surgery. Jumping to consequences might not address the underlying fears or concerns the client has, potentially leading to increased resistance or anxiety.
Choice B rationale:
Initiating a mental health consultation is a valuable step if the client's refusal appears to be influenced by psychological or emotional factors. However, before involving mental health professionals, it's important for the nurse to engage in a direct conversation with the client to explore their thoughts, fears, and reservations.
Choice C rationale:
Discussing the client's concerns about having the surgery is the most appropriate action in this scenario. Engaging in an open and nonjudgmental conversation allows the nurse to understand the client's perspective, provide information, clarify misconceptions, and address any fears or uncertainties. This approach respects the client's autonomy and promotes shared decision-making.
Choice D rationale:
Providing the client with information on additional treatment options might be premature if the client's main concern is related to the current recommended surgery. It's crucial to first address the client's specific reservations before exploring other treatment possibilities.
Correct Answer is D
Explanation
Answer is: Wear an N95 respirator mask when in the client’s room.
Explanation: Pulmonary tuberculosis (TB) is a contagious disease caused by bacteria that can spread through the air. The most common way of transmission is through respiratory droplets that are expelled when a person with active TB coughs, sneezes, or speaks1. Therefore, the charge nurse should expect the newly licensed nurse to take precautions to protect themselves and the client from exposure to TB. One of these precautions is to wear an N95 respirator mask when in the client’s room2. An N95 respirator mask is a type of personal protective equipment (PPE) that filters out at least 95% of airborne particles, including bacteria and viruses3. It can prevent the nurse from inhaling or spreading TB to others.
The other options are incorrect because:
Place the client on droplet precautions: Droplet precautions are not enough to prevent transmission of TB, as they only protect against respiratory droplets that are less than 5 micrometers in diameter1. However, TB bacteria can be found in larger droplets that can travel farther and infect people who are not in direct contact with the source1.
Place the client in a room with positive-pressure airflow: Positive-pressure airflow is not effective against TB, as it does not reduce the concentration of airborne particles or prevent them from escaping through cracks and gaps in doors and windows. Moreover, positive-pressure airflow can create negative pressure in other areas of the facility, which can increase the risk of cross-contamination.
Wear a surgical mask when taking the client out of the room: A surgical mask is not sufficient to protect against TB, as it only filters out particles that are larger than 5 micrometers in diameter3. It also does not fit properly on the face and may allow some particles to pass through3.
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