A nurse is planning to assess a group of four postoperative clients. Which of the following clients should the nurse assess first?
A client who received an antiemetic and still reports nausea
A client whose urine output has averaged 32 mL/hr for the past 24 hr
A client whose heart rate has increased, and blood pressure has dropped
A client who reports their pain level as 8 on a scale of 0 to 10
The Correct Answer is C
A. Persistent nausea is uncomfortable but not immediately life-threatening.
B. Urine output of 32 mL/hr is low but may not be an urgent emergency without other signs.
C. An increased heart rate with a drop in blood pressure indicates possible shock or bleeding and requires immediate assessment.
D. Severe pain requires timely intervention but is not as immediately critical as vital sign instability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
In mass casualty triage, clients are categorized using a color-coded tagging system to prioritize care based on the severity of injuries and the likelihood of survival with immediate treatment. The red tagis assigned to clients who have life-threatening but survivable injuriesand require immediate medical attention.
Rationale
- Client 1: Open head trauma, actively dying.
➤This client is in the expectant (black tag)category. Although the injury is critical, the chance of survival is minimal even with treatment. Resources should be conserved for those more likely to survive. - Client 2: Sucking chest wound, difficulty breathing, HR 119, BP 97/65, RR 40, O2 sat 85%.
➤This client has compromised airway and breathing, and is in respiratory distressbut has a chance of survival with immediate intervention(e.g., chest seal, oxygen). This qualifies them for a red tag—immediate priority. - Client 3: Right ankle sprain and leg abrasions.
➤Minor injuries, stable condition. This client would receive a green tag(walking wounded, delayed care). - Client 4: Partial leg amputation with tourniquet, thready pulse, low BP.
➤This client is in shockbut currently has no active bleedingdue to a tourniquet. Though critical, they are more stable than Client 2. They may qualify for a yellow tag(delayed), unless signs of decompensation appear.
Correct Answer is D
Explanation
A.Posting the diagnosis on the door breaches client confidentiality and is not recommended.
B.Staff should have baseline testing but are not tested solely because of admitting one client with tuberculosis.
C.Household members should be evaluated and possibly treated, but this notification is typically done through public health channels, not the nurse directly.
D.Tuberculosis is a reportable disease; notifying the public health department is mandatory for tracking and controlling outbreaks.
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