A nurse in the emergency department is performing triage for a group of clients who were in a train crash. Which of the following clients should the nurse tag as emergent?
A client who has an open fracture of the femur
A client who has periorbital ecchymosis
A client who has a deep partial thickness burn on the lower extremities
A client who has an asymmetrical thorax
The Correct Answer is D
Rationale for A: An open fracture of the femur is serious and requires prompt treatment, but it does not typically indicate an immediate life threat compared to other conditions.
Rationale for B: Periorbital ecchymosis can indicate facial trauma, but it is not necessarily life-threatening and would not be prioritized as emergent.
Rationale for C: A deep partial thickness burn on the lower extremities is significant and requires treatment, but unless the burn covers a large area or is complicated by other factors, it is not the most critical issue compared to respiratory or cardiovascular threats.
Rationale for D: An asymmetrical thorax may suggest a possible pneumothorax or other significant respiratory issue, which could lead to respiratory distress or failure. This client should be tagged as emergent due to the potential for rapid deterioration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Contacting the nurse manager allows for immediate notification of the incident to someone in authority who can initiate appropriate follow-up and investigation.
B. Involving risk management might be necessary but should come after informing the immediate supervisor or manager.
C. Reassuring the client, while important, should not be the primary action; addressing the issue and initiating appropriate steps should take precedence.
D. Documenting the incident report in the client's chart is important but should follow the immediate notification of the supervisor or manager.
Correct Answer is B
Explanation
A. Calling the pharmacy for a prescription for the client's partner doesn't necessarily violate client confidentiality as it pertains to the partner's care.
B. Providing a copy of the client's medical record to a third party, the transporting paramedic, breaches confidentiality as it exposes the client's private health information to someone not
involved in direct care.
C. Reporting a client's disposition to the referring provider is part of normal care coordination and doesn't typically violate confidentiality.
D. Informing housekeeping staff about a client's location in a specific unit doesn't divulge confidential health information.
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