A nurse is assisting with field triage following a motor-vehicle crash involving a bus with multiple victims. The nurse assesses a child who has an open fracture of the femur. Which action should the nurse take?

Perform a complete head-to-toe assessment.

Notify the emergency department of the child's imminent arrival.

Locate the child's parents to obtain consent for treatment.

Place a yellow triage tag on the child.

Answer and Explanation

The Correct Answer is D

Rationale:

A. In a mass-casualty or field triage situation, time is critical, and the priority is to rapidly identify life-threatening injuries and categorize patients for treatment, rather than performing a detailed head-to-toe assessment on every victim. Complete assessments are performed later once patients are stabilized or brought to definitive care. Spending time on a full assessment in the field could delay care for more critical victims.

B. While notifying the receiving hospital is an important step in disaster response, it is not the immediate priority during initial triage. The nurse’s first responsibility in the field is to assess and categorize patients to determine treatment priority based on the severity of injuries. Communication with the hospital is secondary and occurs after rapid triage.

C. In emergency and disaster situations, consent is implied for urgent or life-threatening injuries. Waiting to locate parents before providing care could delay treatment and put the child at unnecessary risk. Parental consent can be obtained later if needed once the child is stabilized.

D. The child has an open femur fracture, which is a serious injury that requires prompt care but is not immediately life-threatening if airway, breathing, and circulation are stable. In field triage, this type of injury is categorized as yellow (urgent/delayed). Yellow-tagged patients need care after immediate life-threatening cases (red tag) are stabilized, but before minor injuries (green tag). The tag communicates the priority

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Correct Answer is D

Explanation

Rationale:

A. Nutritional support is important in acute pancreatitis, particularly if oral intake is delayed due to NPO status. However, it is not the immediate priority in the initial management of acute pancreatitis.

B. Patient education is essential for long-term management, dietary changes, and prevention of complications, but it is not the priority during the acute phase when the patient is unstable or in severe pain.

C. Pain management is important and should be addressed promptly, but it is secondary to stabilizing vital functions. Severe pain is common in acute pancreatitis, but untreated hypovolemia and shock pose a greater immediate risk to life.

D. Acute pancreatitis often causes third-spacing of fluids, hypovolemia, and risk of shock due to systemic inflammatory response and fluid shifts into the retroperitoneal space. Aggressive intravenous fluid replacement is the priority treatment to maintain perfusion, prevent organ failure, and stabilize the client before other interventions such as pain management or nutrition.

A. " will avoid contact with blood and body fluids." B. "will avoid eating all fish. C. "I will avoid contaminated food and water." D. will wash my hands frequently to prevent fecal-oral transmission." E. "I will use safe sex techniques."

Correct Answer is ["A","E"]

Explanation

Rationale:

A. Avoiding exposure to blood, saliva, semen, vaginal secretions, and other potentially infectious fluids is a primary preventive measure. This includes not sharing needles, razors, or personal items that might be contaminated. Educating the client on safe handling of body fluids is crucial to reducing transmission risk.

B. Dietary restrictions such as avoiding fish are not relevant to preventing hepatitis B. The virus is not transmitted through food, so this statement indicates a misunderstanding of the transmission route.

C. Avoiding contaminated food and water is a preventive measure for hepatitis A, which is spread via the fecal-oral route, not hepatitis B. This strategy does not reduce the risk of hepatitis B infection.

D. Hand hygiene is essential for preventing many infectious diseases, including hepatitis A, gastrointestinal infections, and other pathogens. However, hepatitis B is not spread via the fecal-oral route, so handwashing alone does not directly reduce hepatitis B risk, though it is still good general hygiene practice.

E. Using barrier methods such as condoms, limiting the number of sexual partners, and avoiding sexual contact with infected individuals reduces hepatitis B transmission. Sexual exposure is a significant route of infection, making safe sex education a critical component of preventive teaching.

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A nurse is assisting with field triage following a motor-vehicle crash involving a bus with multiple victims. The nurse assesses a child who has an open fracture of the femur. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse assesses a client admitted to the emergency department with acute pancreatitis. Which treatment should the nurse prioritize?

Correct Answer is D

Explanation

The nurse teaches a client about strategies for reducing the risk of hepatitis B transmission, which statements by the client indicate understanding? Select all that apply.

Correct Answer is ["A","E"]

Explanation

A client is diagnosed with acute pancreatitis. Which laboratory results would the nurse anticipate to be elevated due to OBSTRUCTION in this condition? Select all that apply.

During morning rounds, the nurse notices that a client admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? Select all that apply.

The nurse evaluates a client's response to lactulose treatment. Which finding indicates an expected outcome?

The nurse provides care to a Muslim client who presents to the emergency department with abdominal pain and vaginal bleeding. The client's spouse asks that only a female examines the client. Which is the most culturally appropriate statement by the nurse in response to the request?

A nurse is preparing a teaching plan for a newly married female client with a cervical spinal cord injury who would like to have children someday. The client does not want to become pregnant at this time. What information would be important for the nurse to include? Select all that apply.

Which client admitted to the emergency department should the nurse see first?