A nurse in the emergency department is triaging four clients. Which of the following clients should the nurse recommend to be examined first?

An adolescent client who has an injured ankle and reports a pain level of 8 on a scale from 0 to 10

A toddler who has a 2 cm (0.79 in) head laceration oozing dark red blood

An older adult client who has dyspnea and a respiratory rate of 26/min

An adult client who has large ecchymoses on both legs

Answer and Explanation

The Correct Answer is C

A. An ankle injury with pain is painful but not life-threatening. This client can safely wait.
B. A 2 cm head laceration with dark red blood suggests venous bleeding and is not emergent unless signs of more serious head injury are present.
C. An older adult client with dyspnea and a respiratory rate of 26/min should be examined first. Dyspnea (shortness of breath) and elevated respiratory rate indicate possible respiratory distress or a life-threatening condition such as pulmonary embolism, heart failure, or pneumonia. Airway and breathing issues always take priority.
D. Ecchymoses (bruising) could suggest a bleeding or clotting disorder but are not immediately life-threatening without other symptoms.

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Correct Answer is A

Explanation

A.Droplet precautions require a surgical mask when within 3 feet of a client to prevent transmission of pathogens spread by respiratory droplets, such as influenza.
B.An N95 respirator is required for airborne precautions (e.g., tuberculosis), not droplet precautions.
C.Positive airflow rooms are used for protective environments (e.g., neutropenic clients), not for those on droplet precautions.
D.HEPA filtration systems are typically part of airborne or protective isolation protocols, not required for droplet precautions.

A. Placing the client in a positive-airflow room with 12 air exchanges per hour B. Explaining to the client that he cannot have visitors until his manifestations resolve C. Donning sterile gloves when performing routine oral care D. Wearing a mask when within 1 m (3.3 ft) of the client

Correct Answer is D

Explanation

A.A positive-airflow room with 12 air exchanges per hour is used for protective environments(e.g., neutropenic clients), not for those with droplet infections like streptococcal pharyngitis.
B.Visitors are not prohibitedfor clients with streptococcal pharyngitis. Visitors should follow droplet precautions, such as wearing a mask if close to the client.
C.Sterile glovesare not required for routine oral care; clean glovesare sufficient unless performing a sterile procedure.
D. Streptococcal pharyngitis is spread via droplet transmission. A mask should be worn when within 3 feet (1 meter) of the client to prevent the spread of infection.

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A nurse in the emergency department is triaging four clients. Which of the following clients should the nurse recommend to be examined first?

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Naxlex Comprehensive Predictor Exams

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