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 A
Explanation
The nurse's response demonstrates respect for the client's autonomy, which is the principle of respecting the client's right to make decisions about their own healthcare. The nurse acknowledges the client's right to make a decision and offers support for whatever decision the client makes. Beneficence is the principle of doing good for the client, while nonmaleficence is the principle of avoiding harm. Veracity is the principle of telling the truth to the client, which is not necessarily demonstrated in this scenario.
Correct Answer is C
Explanation
The client's statement that they are afraid of experiencing pain near the end of life may indicate a risk for suicide, as it suggests that the client may be considering suicide as a way to avoid the anticipated pain. The other statements do not necessarily indicate a risk for suicide.
Statement a) may indicate a desire to maintain autonomy and control over their healthcare decisions.
Statement b) may indicate a hopeful attitude, which can be a protective factor against suicide.
Statement d) may indicate a reliance on social support, which can also be a protective factor against suicide.
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