A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?
A conscious adult client who reports shortness of breath, has a respiratory rate of 24/min, and capillary refill of <2 seconds
A conscious adult client who has a dislocated right shoulder, respiratory rate of 18/min, and capillary refill of <2 seconds
An unconscious adult client who has a sucking chest wound, respirations of 38/min, and capillary refill of <2 seconds
An unconscious adult client who has no respirations, capillary refill is 2 seconds and paramedics have already tried to reposition airway without results
The Correct Answer is C
A. This client has respiratory distress but is conscious and stable, requiring urgent but not immediate attention compared to other critical conditions.
B. This client has a dislocated shoulder, which is painful and needs attention but is not life-threatening compared to other conditions.
C. This client is unconscious with a sucking chest wound and high respiratory rate, indicating severe respiratory compromise and needing immediate intervention to prevent further deterioration.
D. This client is also unconscious with no respirations despite attempted airway management, indicating a need for immediate resuscitative efforts, potentially including CPR.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["200"]
Explanation
To calculate the infusion rate in mL/hr for administering ceftriaxone 1 g via intermittent IV bolus over 30 minutes, you would use the formula: (Total Volume in mL / Time in hours) = Rate in mL/hr. In this case, the total volume of the solution is 100 mL, and the time frame is 0.5 hours (since 30 minutes is half an hour). Therefore, the calculation would be 100 mL / 0.5 hours = 200 mL/hr.
Correct Answer is C
Explanation
A. WBCs (White Blood Cells) may be decreased in multiple myeloma due to bone marrow suppression.
B. ANC (Absolute Neutrophil Count) can be decreased due to bone marrow suppression from the disease or treatment.
C. Calcium levels are often elevated in multiple myeloma due to bone breakdown and release of calcium from bone.
D. Platelets may be decreased due to bone marrow suppression as well.
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