A nurse is triaging a group of clients following a disaster. Which of the following clients should the nurse recommend for treatment first?
A client who has bipolar disorder and is exhibiting signs of hallucination
A client who has major burns over 75% of their body surface area
A client who has two open chest wounds with a left tracheal deviation
A client who has a neck injury and is unable to breathe spontaneously
The Correct Answer is D
Choice A reason: A client who has bipolar disorder and is exhibiting signs of hallucination is not the highest priority for treatment. The client may have a psychiatric emergency, but their condition is not life-threatening or unstable. The nurse should assess the client's safety and provide emotional support, but they can wait for further intervention.
Choice B reason: A client who has major burns over 75% of their body surface area is a high priority for treatment, but not the highest. The client has a serious injury that can cause shock, infection, and organ failure. The nurse should monitor the client's vital signs, fluid status, and wound care, but they can wait for a short time.
Choice C reason: A client who has two open chest wounds with a left tracheal deviation is a high priority for treatment, but not the highest. The client has a tension pneumothorax, which is a life-threatening condition that causes air to accumulate in the pleural space and compress the lung and the heart. The nurse should seal the wounds with an occlusive dressing and prepare for chest tube insertion, but they can wait for a few minutes.
Choice D reason: A client who has a neck injury and is unable to breathe spontaneously is the highest priority for treatment. The client has a respiratory emergency, which is the most urgent condition that requires immediate intervention. The nurse should establish an airway, provide oxygen, and stabilize the neck, as well as call for help and notify the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: The client's vital signs are not part of the background information, but rather the assessment information. The background information should include relevant and concise data about the client's history, diagnosis, and treatment.
Choice B reason:The client's name is part of the Situation component, which is the "S" in SBAR. This first step establishes the identity of the patient and the reason for the communication. Background, conversely, focuses on the clinical history and factors that led up to the current situation, rather than basic identifiers used to open the conversation.
Choice C reason:Background information includes the clinical context and history pertinent to the client's care, such as medical history, allergies, and code status. Knowing the code status provides the receiving nurse with essential historical legal and clinical context regarding the client’s wishes and limitations of care, which is a foundational element of the "B" in SBAR.
Choice D reason: A prescribed consultation is not part of the background information, but rather the situation information. The situation information should describe the current problem or reason for the transfer.
Correct Answer is A
Explanation
Choice A reason: Offering to place the purse in the facility safe is the most appropriate action, as it ensures the security and confidentiality of the client's personal belongings. The nurse should document the items in the purse and obtain the client's signature before placing them in the safe.
Choice B reason: Telling the client to leave her purse in a drawer at the bedside is an inappropriate action, as it does not guarantee the safety of the client's personal belongings. The nurse should not leave the client's purse unattended or in an accessible location.
Choice C reason: Offering to store the purse with the nurse's belongings is an inappropriate action, as it violates the professional boundaries and the facility's policy. The nurse should not mix the client's personal belongings with their own, as it may create confusion or conflict.
Choice D reason: Placing the purse underneath the client's sheet is an inappropriate action, as it does not protect the client's personal belongings from theft or damage. The nurse should not hide the client's purse under the sheet, as it may be forgotten or misplaced.
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