A nurse in the emergency department is triaging clients following a mass casualty event. The nurse should identify which of the following clients as emergent?
A client who reports flank pain radiating to the groin
A client who has multiple fractures
A client with partial thickness burns to both hands
A client who has a punctured femoral artery
The Correct Answer is D
A. A client who reports flank pain radiating to the groin: This could indicate renal colic or a kidney stone. While painful and concerning, it is not as immediately life-threatening as severe hemorrhage.
B. A client who has multiple fractures: Multiple fractures are serious but may not be as immediately life-threatening as severe hemorrhage or airway compromise.
C. A client with partial thickness burns to both hands: While painful and needing care, partial thickness burns are less critical compared to life-threatening hemorrhage.
D. A client who has a punctured femoral artery: This is an emergent situation because it involves severe hemorrhage. The femoral artery is a major artery, and puncture could lead to life-threatening blood loss and requires immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Rub the skin completely dry following a decontamination shower: This is incorrect. The skin should be patted dry, not rubbed, to avoid further irritation.
B. Prepare to administer amyl nitrate: This is incorrect. Amyl nitrate is used for cyanide poisoning, not sarin gas exposure.
C. Provide respiratory support with a plastic airway: While respiratory support may be needed, the priority in sarin gas exposure involves addressing symptoms and potential seizures.
D. Initiate seizure precautions: Sarin gas is a nerve agent that can cause seizures due to its effect on the nervous system. Seizure precautions are necessary for clients exposed to sarin gas.
Correct Answer is B
Explanation
A. Manually irrigate the catheter: This action is premature if the issue is due to a kink or obstruction in the tubing. Manual irrigation should only be performed if other less invasive measures do not resolve the issue.
B. Check the catheter tubing for kinks: This is the first step to take as kinks in the tubing can obstruct the flow of urine. Identifying and correcting kinks may resolve the problem without further intervention.
C. Notify the healthcare provider: This step may be necessary if other interventions do not resolve the issue, but it is not the first action.
D. Adjust the rate of the bladder irrigant: This may be relevant if the problem is related to the irrigation rate, but checking for kinks should be done first to ensure proper catheter function.
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