A nurse is planning care for a group of clients. Which of the following clients should the nurse see first?
A client who has a spinal cord injury.
A client who is unconscious.
A client who has peripheral vascular disease.
A client who has a new ankle sprain.
None
None
The Correct Answer is B
Answer: B. A client who is unconscious.
A. A client who has a spinal cord injury.
While a spinal cord injury is serious and requires close monitoring, this condition does not immediately indicate that the client is unstable or at risk for life-threatening complications compared to an unconscious client. However, if there were signs of respiratory compromise or neurogenic shock, this client could be prioritized higher.
B. A client who is unconscious.
An unconscious client should be seen first because their condition may indicate a critical issue such as impaired airway, breathing, or circulation (ABC). Immediate assessment is needed to ensure the airway is clear, breathing is adequate, and circulation is stable, as these are life-threatening concerns.
C. A client who has peripheral vascular disease.
Clients with peripheral vascular disease (PVD) typically have chronic issues related to circulation in the limbs, which can cause pain and discomfort but are not usually immediately life-threatening. While important, this client is not the top priority compared to an unconscious client.
D. A client who has a new ankle sprain.
A new ankle sprain is painful and requires treatment, but it is not life-threatening. The nurse should address this client after ensuring the more urgent needs of other clients are met, such as the unconscious client who may require immediate interventions to preserve life.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
- Remove protective gown before removing gloves.
When caring for a client with Clostridium Difficile, it is important to follow strict contact precautions to prevent the spread of the bacteria. The nurse should remove the protective gown before removing gloves to avoid contaminating the gown with any bacteria that may be on the gloves. This helps to minimize the risk of spreading the bacteria to other clients or healthcare workers.
- Shake bed linens before placing them in a linen bag.
Shaking bed linens can cause any bacteria that may be on them to become airborne, increasing the risk of spreading the bacteria to other surfaces. Instead, bed linens should be rolled up and placed directly into a linen bag without shaking them.
- Use an electronic thermometer to take the client's temperature.
An electronic thermometer is preferred when taking the temperature of a client with Clostridium Difficile because it can be easily disinfected between uses, reducing the risk of spreading the bacteria.
- Remove protective gloves when leaving the client's room.
Protective gloves should be removed before leaving the client's room to avoid contaminating other surfaces or spreading the bacteria to other clients or healthcare workers.
Correct Answer is B
Explanation
The correct answer is b.
Choice A: SpO2 95%
The normal range for SpO2, or peripheral capillary oxygen saturation, is typically between 95% and 100%. While a SpO2 of 95% is within the normal range, it doesn't necessarily indicate an understanding of vital signs as it's on the lower end of the normal range.
Choice B: Right radial pulse regular 68/min
The normal resting heart rate for adults ranges from 60 to 100 beats per minute. Therefore, a right radial pulse of 68 beats per minute falls within the normal range and indicates an understanding of vital signs.
Choice C: Temp 36°C (96.8°F)
The normal body temperature for a healthy adult can range from 97.8°F (36.5°C) to 99.1°F (37.3°C). Therefore, a body temperature of 36°C (96.8°F) is slightly below the normal range.
Choice D: BP 148/72 mm Hg
The normal range for blood pressure in adults is between 90/60 mmHg and 120/80 mmHg. A blood pressure reading of 148/72 mm Hg is above the normal range for systolic pressure (the top number), indicating high blood pressure (hypertension).
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.