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
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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Related Questions
Correct Answer is D
Explanation
Choice A reason: A middle adult client who leaves the facility against medical advice does not require the involvement of the ethics committee. The nurse should document the client's decision, inform the provider, and provide discharge instructions.
Choice B reason: A young adult client who is participating in a medical research study does not require the involvement of the ethics committee. The nurse should ensure that the client has given informed consent and is aware of the potential risks and benefits of the study.
Choice C reason: An older adult client who has advance directives on file does not require the involvement of the ethics committee. The nurse should respect the client's wishes and follow the directives in case of a life-threatening situation.
Choice D reason: An adolescent client whose parents refuse a blood transfusion for religious reasons requires the involvement of the ethics committee. The nurse should consult the ethics committee to help resolve the conflict between the parents' beliefs and the client's best interests. The ethics committee can also provide guidance on the legal and ethical implications of the situation.
Correct Answer is C
Explanation
Choice A reason: Documenting the concern in the nurse's notes is not an appropriate action. The nurse's notes are for recording the client's condition and the care provided, not for expressing the nurse's personal issues. This action does not address the problem or ensure the safety of the clients.
Choice B reason: Requesting help from the personnel on the unit is a good action, but not the best one. The nurse should seek assistance and guidance from experienced staff members, but they should also communicate their concern to the nurse manager, who is responsible for making appropriate assignments and providing support and resources.
Choice C reason: Contacting the nurse manager to discuss the situation is the best action. The nurse manager can evaluate the nurse's competency and experience level, and adjust the assignment accordingly. The nurse manager can also provide feedback, education, and supervision to the nurse to enhance their skills and confidence.
Choice D reason: Refusing to accept the assignment is not an appropriate action. The nurse has a professional and ethical obligation to provide care to the clients, unless there is a clear conflict of interest or violation of standards. The nurse should not abandon the clients or the unit without a valid reason.
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