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 A

Explanation

Choice A reason: Malignant melanoma is a type of skin cancer that often presents as a mole that changes in size, color, and appearance. The description of the lesion being dark brownish-black with irregular borders is characteristic of malignant melanoma. This type of cancer can metastasize rapidly and requires prompt medical intervention for diagnosis and treatment.

Choice B reason: Basal cell carcinoma typically appears as a pearly or waxy bump, often with visible blood vessels. It is less likely to present as a dark, irregularly bordered lesion. Basal cell carcinoma is generally slow-growing and less likely to change rapidly in size and color compared to malignant melanoma.

Choice C reason: Squamous cell carcinoma often presents as a red, scaly, and thickened patch on the skin, sometimes with a crusted or ulcerated surface. While it can change in size, it does not typically appear as a dark, irregularly bordered lesion. Squamous cell carcinoma usually develops in areas of the skin exposed to the sun and has a different presentation compared to malignant melanoma.

Choice D reason: Kaposi's sarcoma presents as purplish, reddish-blue, or dark brown lesions that are often flat or slightly raised. These lesions are common in clients with AIDS but are usually smaller and less likely to have irregular borders compared to malignant melanoma. The description provided is more consistent with malignant melanoma than Kaposi's sarcoma.

A. "I took a laxative yesterday." B. "I took my metformin before breakfast." C. "I haven't had anything to eat or drink since last night." D. "The last time I voided it was painful."

Correct Answer is B

Explanation

Choice A reason: Taking a laxative the day before an IVP is a common preparation to clear the intestines for better imaging. This statement does not require additional data collection.

Choice B reason: The correct answer is b because taking metformin before an IVP can increase the risk of lactic acidosis, a serious complication. Metformin should be temporarily discontinued before and after the procedure, and the nurse should gather more information to manage the client’s diabetes safely.

Choice C reason: Fasting before an IVP is standard procedure to ensure clear imaging. This statement does not require additional data collection.

Choice D reason: Painful voiding may be related to kidney stones but is not a contraindication for an IVP. This statement does not require additional data collection.

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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

Correct Answer is A

Explanation

A nurse is caring for a client who has recurrent kidney stones and a history of diabetes mellitus. The client is scheduled for an intravenous pyelogram (IVP). The nurse should collect additional data about which of the following statements made by the client?

Correct Answer is B

Explanation

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