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 C
Explanation
A. Giving acetaminophen is appropriate for fever reduction but does not address the hypotension and potential dehydration in this scenario.
B. Providing oxygen is important, but the patient's hypotension requires fluid resuscitation as the initial priority.
C. Applying wet sheets and a fan are immediate actions focused on rapid cooling. The priority is to lower the body temperature as quickly as possible to prevent organ damage.
D. Starting lactated Ringer's solution at a high rate is crucial to address hypovolemia and to cool the patient effectively through intravenous hydration but should be done after cooling the patient using a wet sheet.
Correct Answer is B
Explanation
A. Taking salt tablets can lead to electrolyte imbalances and is not recommended for managing heat-related issues.
B. Drinking extra fluids helps prevent dehydration and is an effective measure to prevent heat-related illness.
C. Moving to a cool environment when feeling confused is important but is a reactive measure rather than preventive teaching.
D. Taking acetaminophen for feeling too warm does not address the underlying issue of heat-related illness and is not appropriate discharge teaching for this situation.
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