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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Secure the client's restraints with a square knot
This is incorrect because square knots are difficult to release in an emergency. Quick-release knots are recommended for safety.
B. Attach the restraints to the fixed portion of the frame of the client's bed
This is correct because attaching restraints to the bed frame ensures they remain stable and do not pose a risk if the bed position changes. Restraints should never be attached to movable parts like side rails, as this can lead to injury.
C. Remove the client's restraints every 2 hours
This is a common practice, but not specific enough for the primary focus of the question. While restraints should be removed periodically to check for circulation, skin integrity, and range of motion, the interval might vary based on institutional policy and patient needs.
D. Allow 1 fingerbreadth between the restraint and the client's wrists
This is incorrect because the proper fit is typically 2 fingers to ensure the restraint is snug but not too tight, preventing circulation issues or injury.
Correct Answer is C
Explanation
The correct answer is c.
Choice A reason: Providing the UAP with the infection control policy is not the first action the charge nurse should take. The charge nurse should first assess the UAP's knowledge and understanding of HIV transmission and infection control measures.
Choice B reason: Offering to assist the UAP with the collection of the specimen is not the first action the charge nurse should take. The charge nurse should first address the UAP's fear and educate the UAP about HIV transmission and infection control measures.
Choice C reason: Determining the UAP's knowledge about HIV transmission is the first action the charge nurse should take. This will help the charge nurse identify any knowledge gaps or misconceptions the UAP may have and provide appropriate education and reassurance.
Choice D reason: Demonstrating the proper use of personal protective equipment is not the first action the charge nurse should take. The charge nurse should first assess the UAP's knowledge and understanding of HIV transmission and infection control measures.
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