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 A
Explanation
The correct answer is choice A: Compare data from clients' records regarding skin integrity with established criteria.
Choice A rationale:
Comparing data from clients' records regarding skin integrity with established criteria (Choice A) is essential for evaluating the effectiveness of the plan to decrease pressure injuries. This action helps identify trends, improvements, or areas that still need attention.
Choice B rationale:
Measuring staff attendance at an educational program on managing pressure injuries (Choice B) assesses staff participation but does not directly evaluate the plan's impact on pressure injury rates. Attendance does not necessarily translate to improved implementation.
Choice C rationale:
Interviewing clients regarding their satisfaction with their care (Choice C) focuses on client satisfaction rather than evaluating the effectiveness of the plan in reducing pressure injuries. While satisfaction is important, it does not directly measure the plan's success.
Choice D rationale:
Monitoring use of supplies used to prevent pressure injuries (Choice D) provides information on resource utilization but does not provide comprehensive data on the plan's effectiveness. It does not account for the effectiveness of staff adherence to pressure injury prevention protocols.
Correct Answer is C
Explanation
Choice A rationale:
Notify the charge nurse of the client's request for transfer. This action might be taken eventually, but it is not the first step. The nurse should directly address the client's concerns before escalating the situation to the charge nurse.
Choice B rationale:
Assure the client that their concern has been shared with the staff. Tell the client that future calls will be answered in a timely manner. While it's important to reassure the client, promising timely responses to calls before understanding their expectations might not effectively address the underlying issue. It's better to communicate openly with the client first.
Choice C rationale:
Ask the client to verbalize their expectations. This is the correct choice. By asking the client to express their expectations, the nurse can gather crucial information about the client's concerns and needs. This allows the nurse to address the specific issues that led to the client's dissatisfaction and work toward a resolution that aligns with the client's preferences.
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