A nurse is assisting with triaging clients after a mass casualty event. Which of the following clients should the nurse attend to first?

A client who has a splinted open fracture of the left medial malleolus.

A client who has a penetrating head injury and is experiencing seizures.

A client who has severe respiratory stridor and a deviated trachea.

A client who has a small circular partial-thickness burn of the left calf.

Answer and Explanation

The Correct Answer is C

Choice A reason: An open fracture, while needing medical attention, is not immediately life-threatening. The client's condition is stable enough to wait while more critical cases are attended to.

Choice B reason: A penetrating head injury with seizures is a critical condition. However, ensuring a patent airway takes precedence in emergency situations. This client's seizures indicate serious brain injury, but the immediate threat to life, such as airway obstruction, must be prioritized.

Choice C reason: Severe respiratory stridor and a deviated trachea indicate a life-threatening airway obstruction. This client needs immediate attention to secure the airway and prevent respiratory failure. This is the highest priority because without a clear airway, the client will not survive long enough to benefit from other interventions.

Choice D reason: A partial-thickness burn, although painful and requiring treatment, is not immediately life-threatening. This client can safely wait while those with more critical needs are attended to.

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Correct Answer is D

Explanation

Choice A reason: An apical pulse rate different than the radial pulse rate is known as a pulse deficit, which can indicate atrial fibrillation or other cardiac arrhythmias, but it is not related to paradoxical blood pressure or constrictive pericarditis.

Choice B reason: An increase in heart rate by 20% when standing is indicative of orthostatic hypotension, not paradoxical blood pressure. This condition involves a drop in blood pressure upon standing, leading to a compensatory increase in heart rate.

Choice C reason: A drop in systolic BP by 20 mm Hg when moving from a lying to a sitting position is another indicator of orthostatic hypotension, not paradoxical blood pressure.

Choice D reason: The correct answer is d because a drop in systolic BP of more than 10 mm Hg on inspiration, known as pulsus paradoxus, is a characteristic finding in constrictive pericarditis. This occurs due to the impaired filling of the heart during inspiration, leading to a significant drop in systolic blood pressure.

A. Place the client on a low-sodium diet. B. Encourage increased fluid intake. C. Obtain weekly weight. D. Encourage frequent ambulation.

Correct Answer is A

Explanation

Choice A reason: A low-sodium diet is essential for clients with acute glomerulonephritis to prevent fluid retention and reduce the workload on the kidneys. This dietary modification helps manage edema and hypertension, common complications of the condition. By limiting sodium intake, the body retains less water, which helps control swelling and blood pressure, making it a crucial intervention in the plan of care.

Choice B reason: Encouraging increased fluid intake is not recommended for clients with acute glomerulonephritis. Excessive fluid intake can lead to fluid overload, worsening edema and hypertension. The kidneys are already compromised in their ability to excrete fluid efficiently, so increasing fluid intake would exacerbate these issues. Instead, fluid intake should be carefully monitored and potentially restricted to prevent further strain on the kidneys.

Choice C reason: Obtaining weekly weight is not specific enough to monitor the acute phase of glomerulonephritis. Daily weights are more appropriate to closely monitor fluid balance and detect changes in edema. Daily weight measurements can help in assessing the effectiveness of interventions such as a low-sodium diet or diuretics and provide timely information for adjusting the plan of care.

Choice D reason: Encouraging frequent ambulation, while generally beneficial for overall health, is not a specific intervention for managing acute glomerulonephritis. The primary focus should be on dietary modifications and monitoring fluid balance to manage symptoms and prevent complications. Ambulation should be encouraged based on the client's overall condition and ability but is not a direct intervention for glomerulonephritis.

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A nurse is assisting with triaging clients after a mass casualty event. Which of the following clients should the nurse attend to first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is checking for paradoxical blood pressure on a client who has constrictive pericarditis. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is assisting in the planning of care for a client who has acute glomerulonephritis. Which of the following interventions should the nurse recommend including in the plan of care?

Correct Answer is A

Explanation

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