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 {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
A. Docusate sodium suppositories are commonly used to prevent constipation, which is important postoperatively, especially if the client is experiencing decreased bowel sounds and reports feeling bloated.
B. Ice application can help reduce swelling (edema) in the scrotal and penile area, which is noted in the client's assessment. This can help alleviate discomfort and promote healing.
C. Antispasmodic medications can help manage bladder spasms, which are common postoperatively due to the presence of an indwelling urinary catheter and continuous bladder irrigation.
D. While changing positions is important to prevent complications like pressure ulcers and promote comfort, specifically placing the client in a sitting position while in bed may not be necessary and could potentially interfere with postoperative recovery and comfort.
E. Teaching the client how to use a leg bag for urinary drainage is important, especially if the client will be discharged with a catheter. This education ensures the client can manage their urinary drainage system effectively.
Correct Answer is C
Explanation
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.
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