A nurse is assisting with triaging clients following an explosion. Which of the following clients should the nurse identify as the highest priority?

A conscious adult client who has second-degree burns on both lower legs; respiratory rate is > 30/min

A conscious adult client wearing a medic-alert diabetic bracelet, client reports feeling clammy and shaky.

An unconscious adult client who has a large head wound with gray matter exposed; absent respirations

An unconscious 6-month-old infant with no respirations, no visible injuries

Answer and Explanation

The Correct Answer is C

A. This client has significant burns but is conscious and breathing, indicating adequate airway and respiratory effort.
B. This client is conscious but has symptoms potentially related to hypoglycemia rather than life-threatening injuries.
C. This client is unconscious with a severe head injury and absent respirations, indicating a compromised airway and immediate life-threatening condition.
D. This infant is unconscious with no respirations, requiring immediate attention but is not as urgent as the client with the severe head injury and compromised airway.

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Correct Answer is C

Explanation

A. Applying a warm pack can increase the absorption of venom and worsen symptoms.
B. Applying a tourniquet can restrict blood flow and worsen local effects of the venom.
C. Removing the stinger by scraping it off with a knife blade is the correct method to prevent further venom injection.
D. Sucking the wound can introduce infection and is not recommended.

A. Administer a docusate sodium suppository. B. Apply ice to the scrotum and penis. C. Administer an antispasmodic medication. D. Place the client in the sitting position while in bed. E. Teach the client how to use a leg bag.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

A. Docusate sodium suppositories are commonly used to prevent constipation, which is important postoperatively, especially if the client is experiencing decreased bowel sounds and reports feeling bloated.

B. Ice application can help reduce swelling (edema) in the scrotal and penile area, which is noted in the client's assessment. This can help alleviate discomfort and promote healing.

C. Antispasmodic medications can help manage bladder spasms, which are common postoperatively due to the presence of an indwelling urinary catheter and continuous bladder irrigation.

D. While changing positions is important to prevent complications like pressure ulcers and promote comfort, specifically placing the client in a sitting position while in bed may not be necessary and could potentially interfere with postoperative recovery and comfort.

E. Teaching the client how to use a leg bag for urinary drainage is important, especially if the client will be discharged with a catheter. This education ensures the client can manage their urinary drainage system effectively.

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A nurse is assisting with triaging clients following an explosion. Which of the following clients should the nurse identify as the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a group of clients about first aid care for a bee sting. Which of the following information should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who has had an open radical prostatectomy. Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

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