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
Regular exercise is an essential component of health promotion for older adults. Exercise helps to maintain and improve physical function, mobility, and independence, reduces the risk of falls, and helps to prevent chronic conditions such as diabetes, cardiovascular disease, and osteoporosis. Exercise also has mental health benefits, such as reducing depression and anxiety.
Scheduling annual dental examinations for the clients (A) is important but is not the best health promotion strategy for older adults at an assisted living facility. While dental health is important, exercise is a more comprehensive strategy that addresses multiple aspects of health.
Providing the clients with a low-fat diet (B) is also important for health promotion, but it is not as effective as exercise in promoting physical and mental health.
Immunizing the clients against influenza (D) is important to prevent infection, but it is not a health promotion strategy that addresses overall health and wellbeing.
Correct Answer is B
Explanation
Hepatitis A is primarily transmited through the fecal-oral route, meaning that the virus is present in the stool of infected individuals and can be spread through contaminated food, water, or surfaces. Therefore, the reservoir for hepatitis A is the gastrointestinal tract of infected individuals, specifically their feces.
Blood (A) is not a reservoir for hepatitis A, as the virus is not typically present in the blood.
The genitourinary tract (C) and skin (D) are also not reservoirs for hepatitis A, as the virus is not typically present in these areas.
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