A nurse in the emergency department (ED) is triaging four clients following a mass casualty event. The nurse should identify which of the following clients as emergent?
A client who has a leg and ankle fracture
A client who reports flank pain radiating to the groin
A client who has a raised red rash on the abdomen
A client who has expiratory stridor
The Correct Answer is D
A. A leg and ankle fracture is serious but typically not life-threatening compared to issues involving airway obstruction or severe bleeding.
B. Flank pain radiating to the groin may indicate a kidney stone or other condition, but it is less urgent than airway obstruction.
C. A raised red rash on the abdomen could be a sign of a less urgent condition, such as a viral infection or allergic reaction, and does not require immediate intervention compared to respiratory distress.
D. Expiratory stridor indicates upper airway obstruction or severe respiratory distress, which is a life-threatening condition requiring immediate intervention. Stridor suggests possible airway compromise, which needs to be addressed urgently to prevent respiratory failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Assessing for upper extremity injuries is important, but it is not the highest priority in an unconscious client who is at risk for airway obstruction.
B. Suctioning saliva from the client's mouth is the highest priority because an unconscious client is at risk for airway obstruction due to the accumulation of saliva or other secretions. Maintaining a clear airway is essential to prevent aspiration and ensure adequate oxygenation.
C. Monitoring electrolyte levels is important in the overall management of a client with cerebral hemorrhage, but it is not the immediate priority compared to securing the airway.
D. Recording intake and output is necessary for fluid balance monitoring but is secondary to the immediate need to maintain a patent airway in an unconscious client.
Correct Answer is C
Explanation
A. An HbA1c level of 7.5% indicates suboptimal long-term glucose control. The target for many diabetic patients is usually below 7%, but it may not require immediate action compared to more acute indicators.
B. A 2-hour post-prandial blood glucose level of 122 mg/dL is slightly above the normal range but not significantly high. This result alone is not as indicative of inadequate control as other values.
C. A random blood glucose level of 300 mg/dL is significantly elevated and indicates poor glucose control. This value is much higher than the normal range and suggests a need for further teaching and adjustment of diabetes management.
D. A fasting blood glucose level of 48 mg/dL is low and could indicate hypoglycemia rather than inadequate control. This level requires immediate attention but does not reflect poor long-term diabetes management.
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