A nurse is triaging clients following a mass casualty accident. Which of the following clients should be the nurse's priority?

A client who has an open fractured femur and reports severe pain

A client who has vomited twice and has contusions to both arms and shoulders

A client who has a metal bar protruding from the upper abdomen and is hyperventilating

A client who has several large lacerations to the upper extremities and can explain what occurred

Answer and Explanation

The Correct Answer is C

A) A client who has an open fractured femur and reports severe pain:
An open fractured femur is a serious injury that requires attention due to the risk of infection and bleeding. However, it is not as immediately life-threatening as the complications associated with a protruding metal bar and hyperventilation. The severe pain, while significant, is secondary to addressing the most life-threatening conditions.

B) A client who has vomited twice and has contusions to both arms and shoulders:
While this client may be experiencing symptoms of potential internal injuries or trauma, vomiting and contusions alone do not indicate an immediate life-threatening situation compared to the other conditions. Further assessment is needed, but this client is not the priority in a mass casualty situation.

C) A client who has a metal bar protruding from the upper abdomen and is hyperventilating:
A metal bar protruding from the upper abdomen poses an immediate threat to vital organs, such as the liver, spleen, or intestines, and can cause severe internal bleeding or damage. Hyperventilation indicates possible hypoxia or shock. This client is the highest priority as they face the greatest immediate risk of life-threatening injury.

D) A client who has several large lacerations to the upper extremities and can explain what occurred:
Large lacerations need attention to prevent infection and control bleeding. However, the ability to explain the situation and the absence of immediate life-threatening signs suggest that this client’s condition is less critical compared to others with more severe or life-threatening injuries.

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Correct Answer is B

Explanation

A) Use a 3 ml syringe when flushing the PICC line:
Using a 3 ml syringe for flushing is not recommended. Smaller syringes generate higher pressure, which can damage the catheter. Instead, a 10 ml syringe is typically used to flush PICC lines to ensure safe pressure levels.
B) Flush the PICC line with 0.9% sodium chloride after medication administration:
Flushing the PICC line with 0.9% sodium chloride after medication administration is standard practice. It helps clear the line of any residual medication, preventing drug interactions and ensuring the line remains patent.
C) Expect the PICC line to be inserted into a lower extremity vein:
PICC lines are typically inserted into veins in the upper extremities, such as the basilic, brachial, or cephalic veins, rather than lower extremity veins. This positioning reduces the risk of complications and allows for better access and care.
D) Monitor for a pneumothorax following insertion of the PICC line:
Monitoring for a pneumothorax is not typically necessary following PICC line insertion. Pneumothorax is a potential complication of central venous catheter placements involving the subclavian or jugular veins, not the peripheral veins used for PICC lines. Instead, complications like infection, thrombosis, and catheter occlusion are more relevant concerns.

A. Discard samples that contain urine. B. Collect three samples from a single bowel movement. C. Wear sterile gloves when collecting the sample. D. Take the sample from the outer edge of formed stool.

Correct Answer is A

Explanation

A. Discard samples that contain urine:
Urine contamination can interfere with the accuracy of a fecal occult blood test (FOBT). The presence of urine can dilute the stool sample and potentially alter the test results. Therefore, it is essential to discard any samples that are contaminated with urine to ensure the reliability of the test.

B. Collect three samples from a single bowel movement:
For a guaiac-based FOBT, it is recommended to collect samples from different bowel movements rather than a single one. This increases the likelihood of detecting intermittent bleeding. Collecting three samples from different bowel movements over a few days can provide a more accurate assessment of occult blood.

C. Wear sterile gloves when collecting the sample:
While gloves should be worn for protection and hygiene purposes, sterile gloves are not necessary for collecting stool samples for FOBT. Clean, non-sterile gloves are adequate to prevent contamination and ensure safe handling of the specimen.

D. Take the sample from the outer edge of formed stool:
For a guaiac smear, samples should ideally be taken from various parts of the stool, not just the outer edge, to increase the chance of detecting occult blood. Taking a small amount from different areas of the stool can provide a more representative sample for accurate testing.

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A nurse is triaging clients following a mass casualty accident. Which of the following clients should be the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who requires insertion of a peripherally inserted central catheter (PICC) line. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse is preparing to obtain a guaiac smear sample from a client for fecal occult blood testing. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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