A nurse is triaging clients who were involved in a commuter train crash. Which of the following clients should the nurse choose for transport to the emergency department first?
A client who has full thickness burn injuries over 30% of his total body surface area.
A client who has a fracture of the humerus with a 2nd radial pulse in the affected arm.
A client who is exhibiting agonal respirations with fixed and dilated pupils.
An ambulatory client who has a nosebleed and reports feeling dizzy.
The Correct Answer is C
In a triage situation, the nurse should prioritize clients based on the severity of their condition and the potential for their condition to deteriorate rapidly. A client who is exhibiting agonal respirations with fixed and dilated pupils is likely experiencing a life-threatening emergency, such as respiratory or cardiac arrest, and should be transported to the emergency department first.
The nurse should initiate immediate resuscitation efforts and notify the emergency department of the client's condition.
The client with full- thickness burn injuries over 30% of his total body surface area should be transported next, as this is also a life-threatening emergency.
The client with a fracture of the humerus with a 2nd radial pulse in the affected arm can wait a bit longer as he has a palpable radial pulse indicating circulation is maintained.
The ambulatory client with a nosebleed and feeling dizzy is the least critical and can be managed in a non- emergency setting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A nurse case manager plays various roles in coordinating and managing the care of clients. One of these roles is acting as a coordinator, which involves facilitating the delivery of care and services that are necessary for a client's safe and effective transition from one level of care to another.
Arranging for the delivery of medical equipment to a client's home is part of the coordination role, as it ensures that the client has the necessary equipment to manage their condition or treatment at home.
An advocate role involves representing and protecting the interests of the client, while a systems allocator role involves managing resources within a healthcare system.
A consultant role involves providing expert advice or guidance to other healthcare providers.
Correct Answer is D
Explanation
Many migrants may not speak the language of the country they are in, which can create significant barriers to accessing health care. Therefore, it is crucial for the nurse to ensure access to interpretation services, such as hiring bilingual staff or interpreters, or using telephone interpretation services.
Treating illnesses on a fee-for-service basis may be a barrier to accessing care for migrants who may not have insurance or the financial resources to pay for services.
Providing health services at work sites may be helpful, but it may not reach all members of the migrant population.
Offering health screenings at a community center may be helpful, but it may not address the issue of language barriers.
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