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A nurse is triaging a group of clients as they arrive simultaneously in the emergency department following a nearby bus crash

Which of the following clients should the nurse transfer to the three available trauma rooms? Select the 3 clients to transfer for immediate treatment.

Client 1

Client 2

Client 3

Client 4

Client 5

Client 6

Answer and Explanation

Correct Answer : A,D,F

Rationale:

Client 1: The client has a large laceration (10.2 cm) with radial pulses 2+, tachycardia (HR 114/min), and pain 6/10. While the blood pressure is slightly elevated, the client requires immediate trauma care for bleeding control and pain management, making them a priority for a trauma room.
Client 2: This client has bruising and abrasions with stable vital signs and no signs of life-threatening injuries. They can wait for care in a less acute area, so immediate trauma room transfer is not required.
Client 3: The client has minor contusion and nausea, is alert and oriented, and vital signs are stable. This is a lower priority patient, so trauma room transfer is not immediately necessary.
Client 4: The client has a cervical collar in place, absent lower extremity movement, GCS 14, and borderline hypotension. These findings indicate spinal injury and potential neurogenic shock, making the client high priority for immediate trauma care.
Client 5: The client has closed head injury, traumatic amputation, CPR in progress, asystole, fixed pupils, and agonal respirations. This patient is unsalvageable in the current scenario (expectant in mass-casualty triage) and would not occupy a trauma room immediately.
Client 6: The client has hypotension (BP 82/54 mm Hg), tachycardia (HR 124/min), abdominal bruising, and is ambulatory but at risk for internal bleeding or shock, requiring immediate trauma room transfer.

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Correct Answer is B

Explanation

Rationale:
A. The development of an S3 heart sound is a sign of ventricular dysfunction or fluid overload in heart failure. This would indicate worsening cardiac status rather than success of the quality improvement initiative.

B. Decreased brain natriuretic peptide (BNP) levels reflect improved cardiac function and reduced fluid overload. BNP is released in response to ventricular stretch, so lower levels indicate that heart failure is being better managed, which aligns with the goal of reducing readmissions. This is a positive outcome and demonstrates that the quality improvement initiative is effective.

C. Jugular vein distention (JVD) is a clinical sign of right-sided heart failure and fluid overload, indicating that the client’s heart failure is not optimally controlled. This finding would suggest the initiative may not be fully successful.

D. An increased weight of 2.27 kg (5 lb) in one week is an early indicator of fluid retention in heart failure. Rapid weight gain signals worsening volume overload, which would be a negative outcome and not indicative of success.

A. "In the role of client advocate, I should take responsibility for coordinating each client's care." B. "My role as a client advocate is to empower the clients to make informed health care decisions." C. "As a client advocate, I will suggest the best course of action for clients who are indecisive. D. "As a client advocate, I will adhere to the provider's prescribed treatments.

Correct Answer is B

Explanation

Rationale:
A. Coordinating care is part of the nurse’s responsibilities, but it is not the primary role of advocacy. Advocacy focuses on supporting clients’ rights, preferences, and informed decision-making rather than assuming full responsibility for care coordination.

B. Empowering clients to make informed health care decisions is the essence of nursing advocacy. The nurse provides information, clarifies options, and supports the client in expressing their preferences and making decisions that align with their values and goals. This ensures respect for client autonomy.

C. Suggesting the “best” course of action for indecisive clients undermines their autonomy and is not consistent with advocacy. Advocacy means guiding and supporting, not making decisions on behalf of the client unless they lack decisional capacity.

D. Adhering strictly to the provider’s prescribed treatments is part of nursing care but does not reflect advocacy, which may involve questioning or clarifying orders if they conflict with the client’s wishes or best interests.

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A nurse is triaging a group of clients as they arrive simultaneously in the emergency department following a nearby bus crash Which of the following clients should the nurse transfer to the three available trauma rooms? Select the 3 clients to transfer for immediate treatment.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has heart failure two months after the implementation of a quality improvement initiative to reduce the hospital readmission rate. Which of the following findings should the nurse identify as an indication the quality improvement initiative is successful?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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A nurse is triaging a group of clients as they arrive simultaneously in the emergency department following a nearby bus crash

Which of the following clients should the nurse transfer to the three available trauma rooms? Select the 3 clients to transfer for immediate treatment.