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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Closing the fire doors and the doors to the room is an appropriate action, but not the first one that the nurse should take. The nurse should first activate the fire alarm to alert the fire department and the facility staff.
Choice B reason: Extinguishing the fire is an appropriate action, but not the first one that the nurse should take. The nurse should first activate the fire alarm to alert the fire department and the facility staff. Then, the nurse should use the fire extinguisher to put out the fire, following the RACE protocol (rescue, alarm, contain, extinguish).
Choice C reason: Removing clients from nearby rooms is an appropriate action, but not the first one that the nurse should take. The nurse should first activate the fire alarm to alert the fire department and the facility staff. Then, the nurse should evacuate the clients who are in immediate danger, following the RACE protocol (rescue, alarm, contain, extinguish).
Choice D reason: Activating the fire alarm is the first and most appropriate action that the nurse should take. The nurse should activate the fire alarm to alert the fire department and the facility staff. Then, the nurse should follow the RACE protocol (rescue, alarm, contain, extinguish) to protect the clients and the facility.
Correct Answer is C
Explanation
Choice A reason: A respiratory therapist is a health care professional who can provide education and assistance on the use and maintenance of the nebulizer, but not on the financial aspects of obtaining it. The nurse should collaborate with the respiratory therapist to ensure the parent understands how to administer the nebulized medications to the child.
Choice B reason: A pharmacist is a health care professional who can provide information and advice on the medications prescribed for the child, but not on the financial aspects of obtaining the nebulizer. The nurse should consult with the pharmacist to ensure the parent knows how to store and handle the medications safely.
Choice C reason: A social worker is a health care professional who can provide support and resources to the parent regarding the financial aspects of obtaining the nebulizer. The nurse should refer the parent to the social worker to explore options such as insurance coverage, payment plans, or assistance programs.
Choice D reason: Child protective services is an agency that investigates and intervenes in cases of child abuse or neglect. The nurse should not refer the parent to child protective services, as this could imply that the parent is intentionally harming or neglecting the child, which is not the case. The nurse should respect the parent's rights and dignity, and offer help and guidance.
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