A triage nurse in an emergency department is caring for a group of clients. Which of the following clients should the nurse assess first?

Client who has a displaced femur fracture from a fall

Client who is experiencing severe vomiting and diarrhea with tachycardia

Client who is confused and has slurred speech

Client who has chemical burns covering 20% of the total body surface area

Answer and Explanation

The Correct Answer is C

Choice A reason: A client who has a displaced femur fracture from a fall is a priority client, but not the highest priority. The nurse should assess the client for signs of bleeding, infection, nerve damage, and compartment syndrome, and provide pain relief and immobilization. However, the client's condition is not as urgent or life-threatening as the other clients.

Choice B reason: A client who is experiencing severe vomiting and diarrhea with tachycardia is a priority client, but not the highest priority. The nurse should assess the client for signs of dehydration, electrolyte imbalance, and shock, and provide fluid and electrolyte replacement and antiemetic medication. However, the client's condition is not as urgent or life-threatening as the other clients.

Choice C reason: A client who is confused and has slurred speech is the highest priority client, as these are signs of a possible stroke, which is a medical emergency. The nurse should assess the client for other signs of stroke, such as facial drooping, arm weakness, and vision problems, and initiate the stroke protocol, which includes calling for help, obtaining a CT scan, and administering thrombolytic therapy if indicated.

Choice D reason: A client who has chemical burns covering 20% of the total body surface area is a priority client, but not the highest priority. The nurse should assess the client for signs of airway injury, infection, and fluid loss, and provide wound care, pain relief, and fluid resuscitation. However, the client's condition is not as urgent or life-threatening as the other clients.

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Correct Answer is B

Explanation

Choice A reason: The belief that the client has a difficult relationship with his son is not relevant for the change-of-shift report. This is a subjective and personal opinion that does not affect the client's care or recovery.

Choice B reason: The steps to follow when providing wound care is relevant for the change-of-shift report. This is an objective and clinical information that ensures the continuity and quality of the client's care.

Choice C reason: The time the client received his last dose of pain medication is not relevant for the change-of-shift report. This is a routine and standard information that can be found in the medication administration record or the electronic health record.

Choice D reason: The client's preferred time for bathing is not relevant for the change-of-shift report. This is a preference and not a priority information that can be communicated later or documented in the care plan.

A. Demonstrate use of the pump during medication administration. B. Pair an inexperienced nurse with an experienced nurse. C. Plan an in-service education program on the unit. D. Contact the manufacturer of the pump for assistance.

Correct Answer is C

Explanation

Choice A reason: Demonstrating use of the pump during medication administration is not the priority action by the charge nurse. This would not ensure that all staff nurses are competent and confident in using the new pump. It would also interrupt the workflow and patient care.

Choice B reason: Pairing an inexperienced nurse with an experienced nurse is not the priority action by the charge nurse. This would not address the knowledge gap of the staff nurses who are not paired. It would also create a dependency on the experienced nurse and a potential risk for errors.

Choice C reason: Planning an in-service education program on the unit is the priority action by the charge nurse. This would provide the staff nurses with the opportunity to learn about the new pump, its features, functions, and troubleshooting. It would also allow the charge nurse to assess the staff nurses' learning needs and evaluate their competency.

Choice D reason: Contacting the manufacturer of the pump for assistance is not the priority action by the charge nurse. This would not address the immediate needs of the staff nurses who are using the new pump. It would also depend on the availability and responsiveness of the manufacturer.

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A triage nurse in an emergency department is caring for a group of clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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