Try Naxlex NCLEX-RN (Free-Trial)

A nurse is the triage officer in the emergency department during a disaster when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?

An unconscious adult client who has no respirations, capillary refill is > 2 seconds, and paramedics have already tried to reposition airway without results

A conscious adult client who has a broken tibia, blood pressure of 160/90 mm Hg, and heart rate of 118 beats per minute

An unconscious adult client who has a sucking chest wound, SpO2 of 85%, and capillary refill of < 2 seconds

A conscious adult client who reports shortness of breath, has a respiratory rate of 24/min, and capillary refill of <2 seconds

Answer and Explanation

The Correct Answer is C

C. The unconscious adult client with a sucking chest wound and low SpO2 (85%) is in immediate need of intervention. A sucking chest wound is a life-threatening injury that can lead to respiratory distress and compromised oxygenation. This client requires immediate attention to address the chest wound and improve oxygenation.
A. The unconscious client with no respirations and an ineffective airway attempt is likely beyond rescue, making them lower priority compared to those with potentially reversible conditions.
B. The conscious client with a broken tibia and elevated vital signs is stable enough to be seen after more critical cases are addressed.
D. The conscious client with shortness of breath and a high respiratory rate is concerning but not as immediately life-threatening as a client with a sucking chest wound.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Feeling hot and sweaty can occur during autonomic dysreflexia, but it is a symptom of the condition rather than a cause or risk factor.
B. Bladder distension is a common trigger for autonomic dysreflexia, a condition that occurs in individuals with spinal cord injuries at or above the T6 level, due to the excessive autonomic response to noxious stimuli such as a full bladder.
C. Elevated blood pressure is a sign of autonomic dysreflexia, but the risk factor to recognize is the underlying cause, such as bladder distension.
D. A severe headache is a symptom of autonomic dysreflexia, indicating the need for immediate action, but it is not a risk factor for developing the condition.

A. Instruct the assistive personnel (AP) to focus on clients' activities of daily living (ADLs). B. Focus on providing care to clients with life-threatening emergencies. C. Initiate discharging stable clients for bed availability D. Stock additional unit supplies.

Correct Answer is B

Explanation

B. In a disaster situation, prioritizing care for clients with life-threatening emergencies is crucial to ensure that those in the most critical condition receive immediate attention. This aligns with triage principles and ensures that limited resources are used effectively.
A. While addressing ADLs is important, it is secondary to addressing life-threatening emergencies in a disaster scenario.
C. Discharging stable clients can help increase bed availability but should be considered after addressing immediate life-threatening needs.
D. Stocking additional supplies is necessary but should follow after ensuring that life-threatening conditions are managed.

View Question and Answer

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

A nurse is the triage officer in the emergency department during a disaster when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a T4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

Correct Answer is B

Explanation

A nurse is working with a limited staff because of a severe storm in the area. The facility incident commander has initiated disaster protocols. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is providing education about levothyroxine to a client diagnosed with primary hypothyroidism. Which of the following statements should the nurse use when teaching the client?

A diabetes nurse educator is discussing "sick day rules" with a client newly diagnosed with diabetes mellitus type 1. Which statement by the client indicates a need for further teaching?

A client arrives in the emergency department with an ischemic stroke. What is the priority for the nurse to assess in relation to the administration of tissue plasminogen activator (t-PA) as treatment?

A nurse is caring for a 38-year-old client who presents to the emergency department (ED) in pain. Exhibits For each potential healthcare provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

A nurse is caring for a 72-year-old client who has type 1 diabetes mellitus. Exhibits Select the 3 findings that require immediate follow-up.

A nurse is assessing a client who has Parkinson disease. Which of the following manifestations should the nurse expect?

A nurse is caring for a 43-year-old client who has human immunodeficiency virus (HIV). Exhibits Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing dropdown and dropdown