A nurse is performing triage for a group of clients following a mass casualty incident (MCI). Which of the following clients should the nurse plan to care for first?

A client who has an open upper extremity fracture

A client experiencing a tension pneumothorax

A client who has full-thickness burns over 85% of their body

A client who has agonal respirations

Answer and Explanation

The Correct Answer is B

A. A client who has an open upper extremity fracture: While this is a serious injury, it is less critical compared to a tension pneumothorax in a triage setting.
B. A client experiencing a tension pneumothorax: This is a life-threatening condition that requires immediate intervention to relieve pressure on the lungs and restore adequate breathing.
C. A client who has full-thickness burns over 85% of their body: This is a severe condition with a high mortality risk, but in a mass casualty situation, a tension pneumothorax is prioritized for immediate care.
D. A client who has agonal respirations: Agonal respirations indicate severe distress, but the immediate need for intervention is to address conditions that can rapidly compromise life, such as a tension pneumothorax.

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Correct Answer is C

Explanation

A. Ensure the client's intake is greater than their output: This is incorrect. In continuous bladder irrigation, the output may exceed the intake because the irrigation fluid is used to flush the bladder. The focus should be on ensuring proper drainage and monitoring for clots or obstruction rather than ensuring intake exceeds output.
B. Monitor the client's urine output every eight hours: This is incorrect. Following a transurethral resection of the prostate with continuous bladder irrigation, urine output should be monitored more frequently to ensure the irrigation system is functioning properly and to assess for signs of bleeding or obstruction.
C. Remind the client he might feel a constant urge to void: This is correct. It is common for clients to experience a constant urge to void due to bladder irritation and the presence of the catheter.
D. Assess for manifestations of fluid volume deficiency: This is incorrect. The primary concern with continuous bladder irrigation is monitoring for signs of bleeding or obstruction rather than fluid volume deficiency. Fluid balance is monitored based on intake and output, but deficiency is less likely in this context.

A. Hormone therapy decreases the risk of cardiovascular events. B. Hormone therapy may prevent osteoporotic fractures. C. Hormone therapy should be taken in doses throughout the day. D. If a dose is missed, then the next dose should be doubled.

Correct Answer is B

Explanation

A. Hormone therapy decreases the risk of cardiovascular events: This is incorrect. Hormone therapy can actually increase the risk of cardiovascular events, including heart disease and stroke.
B. Hormone therapy may prevent osteoporotic fractures: This is correct. Hormone therapy can help maintain bone density and reduce the risk of osteoporotic fractures in women undergoing menopause.
C. Hormone therapy should be taken in doses throughout the day: This is incorrect. Hormone therapy is usually taken in a single daily dose or as directed by a healthcare provider, not throughout the day.
D. If a dose is missed, then the next dose should be doubled: This is incorrect. Missing a dose of hormone therapy should be managed according to the provider's instructions, which typically do not involve doubling the next dose.

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A nurse is performing triage for a group of clients following a mass casualty incident (MCI). Which of the following clients should the nurse plan to care for first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is 2 hours postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?

Correct Answer is C

Explanation

A nurse is presenting educational materials to a group of middle-aged clients about menopausal hormone therapy following total hysterectomy. Which of the following information should the nurse include in the education?

Correct Answer is B

Explanation

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