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
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Correct Answer is B
Explanation
Choice A reason: Nurses who have advanced training may provide direct care for clients, but this is not specific to case management. Case management is a collaborative process that involves assessing, planning, implementing, coordinating, monitoring, and evaluating the options and services required to meet the client's health and human service needs.
Choice B reason: Nurses use critical pathways when caring for clients as part of case management. Critical pathways are standardized plans of care that outline the expected outcomes, interventions, and time frames for a specific diagnosis or procedure. They help to ensure quality, continuity, and cost-effectiveness of care.
Choice C reason: Nurses delegate and supervise assigned tasks, but this is a general nursing responsibility and not specific to case management. Case management requires more than just task delegation and supervision. It also involves communication, coordination, and evaluation of care.
Choice D reason: The nurse completes one specific task for a group of clients is not an accurate description of case management. Case management is not task-oriented, but client-centered and outcome-focused. The nurse is responsible for the overall care of the client, not just one aspect of it.
Correct Answer is A
Explanation
Choice A reason: Returning unused supplies from the bedside to the unit's supply stock is an appropriate action to include in the cost-containment plan. This action prevents waste and saves money by reusing the supplies that are not contaminated or expired.
Choice B reason: Using clean gloves rather than sterile gloves for colostomy care is not an appropriate action to include in the cost-containment plan. This action compromises the quality and safety of care by increasing the risk of infection and cross-contamination. Sterile gloves are required for colostomy care to prevent introducing microorganisms into the stoma or the pouch.
Choice C reason: Storing opened bottles of normal saline in a refrigerator for up to 48 hours is not an appropriate action to include in the cost-containment plan. This action violates the infection control and medication administration policies. Opened bottles of normal saline should be discarded after 24 hours or after a single use, depending on the facility's protocol. Refrigerating the bottles does not extend their shelf life or sterility.
Choice D reason: Waiting to dispose of sharps containers until they are completely full is not an appropriate action to include in the cost-containment plan. This action poses a hazard and a liability for the staff and the clients. Sharps containers should be disposed of when they are three-quarters full or according to the manufacturer's instructions. Overfilling the containers can cause needlestick injuries or spillage of contaminated materials.
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