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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A rationale:

The nurse should not promise that a social worker will address the client's concerns, as this might not be accurate. While a social worker could be involved in the client's care, it's not their sole responsibility to address all concerns. The primary role of a social worker might be to provide emotional support and assistance with psychosocial issues.

Choice B rationale:

Suggesting that the client should plan to go to a skilled nursing facility after discharge might not be appropriate unless it's medically necessary. Terminal illness often requires a focus on palliative and hospice care rather than transferring to another care facility.

Choice C rationale:

This is the correct choice. The case manager plays a key role in coordinating the various resources and services the client will need after discharge. They ensure a smooth transition from the hospital to home, including arranging for home health care, medical equipment, and any other necessary services.

Choice D rationale:

Telling the client that they will need hospice care until they feel stronger is not appropriate. Hospice care is specifically for individuals with terminal illnesses who have a limited life expectancy. It is not about getting stronger but about providing comfort and support during the end-of-life period.

A. Notify the charge nurse of the client's request for transfer. B. 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. C. Ask the client to verbalize their expectations.

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a terminal illness and voices concern about performing self-care after discharge. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

A client on a general surgical unit tells a nurse that staff members are not answering the call light promptly. The client requests to be transferred to another unit. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A home health nurse is planning her daily visits and receives laboratory results for four adult clients. The nurse should first visit the client who has which of the following laboratory values?

A nurse is receiving report from the assistive personnel (AP) assigned to the nurse's group of clients. Which of the following statements from the AP indicates the client the nurse should assess first?

A charge nurse is leading a committee that is revising the policy for client discharge. After developing the initial plan, which of the following actions should the nurse take next?

A nurse is observing a newly licensed nurse perform a sterile dressing change on a client who has a central venous catheter. Which of the following actions should the newly licensed nurse take?

A nursing unit is undergoing changes to accommodate new bariatric services that will be available on the unit. Some staff members have verbalized displeasure with the changes. Which of the following actions should the charge nurse take?

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A nurse on a quality improvement team is implementing a plan to decrease the rate of pressure injuries in a long-term care facility. Which of the following actions should the team take to evaluate the effectiveness of the plan?

A charge nurse observes that a staff nurse's behavior has changed over the past few weeks. Which of the following behaviors should the charge nurse identify as an indication that the staff nurse might be working while impaired?