An emergency department nurse triages a group of clients who were injured in a school bus crash. Which of the following clients should the nurse have the provider evaluate first?

A client who has a forehead wound that is bleeding copiously

A client who has a compound fracture of the femur and is crying in pain

A client who was unconscious at the scene and now reports diplopia and nausea

A client who has several missing teeth and a swollen, ecchymotic upper lip

Answer and Explanation

The Correct Answer is C

A. A client who has a forehead wound that is bleeding copiously. Although bleeding may appear dramatic, most scalp wounds bleed heavily and can be controlled with pressure. This is not immediately life-threatening if the client is stable.
B. A client who has a compound fracture of the femur and is crying in pain. This is a serious injury with risk for blood loss and infection, but the client is alert and stable enough to express pain, suggesting less immediate neurologic risk than other clients.
C. A client who was unconscious at the scene and now reports diplopia and nausea. This client likely has a head injury with signs of increased intracranial pressure or concussion (diplopia = double vision, nausea, and prior loss of consciousness). These are neurological red flags and require immediate evaluation to prevent deterioration.
D. A client who has several missing teeth and a swollen, ecchymotic upper lip. While painful and concerning, oral trauma without airway compromise is less urgent than potential brain injury.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

An hCG level of 30,000 IU/L is significantly elevated and may suggest a molar pregnancy, especially when values are higher than expected for gestational age. In a molar pregnancy (hydatidiform mole), trophoblastic tissue proliferates abnormally, producing excessive hCG. This level, in combination with normal hemoglobin and hematocrit, makes other causes like spontaneous or induced abortion less likely.

Key Takeaways:

Extremely elevated hCG levels can indicate gestational trophoblastic disease (molar pregnancy).
Molar pregnancy is a nonviable pregnancy characterized by abnormal trophoblast proliferation.
Normal hemoglobin and hematocrit reduce the likelihood of current bleeding or miscarriage.

A. Critical pathways-should reduce health care costs. B. Nurses should discontinue the critical pathway if variances occur. C. Critical pathways have an unlimited timeframe for completion. D. Nurses' notes are used to create the critical pathway.

Correct Answer is A

Explanation

A. Critical pathways should reduce health care costs. Critical pathways, also known as clinical pathways or care maps, are evidence-based, multidisciplinary plans that outline expected care and outcomes for specific conditions. They aim to improve care efficiency, reduce complications, and lower healthcare costs by standardizing care.
B. Nurses should discontinue the critical pathway if variances occur. Variances—deviations from the expected pathway—are documented and analyzed, not a reason to discontinue the pathway. They help identify areas for improvement or necessary adjustments in patient care.
C. Critical pathways have an unlimited timeframe for completion. Critical pathways are time-bound, with specific goals and milestones to be met within a set timeframe based on typical recovery patterns for the condition being treated.
D. Nurses' notes are used to create the critical pathway. Critical pathways are developed using evidence-based guidelines, expert consensus, and clinical research, not individual nurses’ progress notes. However, nurses do document progress and variances within the pathway.

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An emergency department nurse triages a group of clients who were injured in a school bus crash. Which of the following clients should the nurse have the provider evaluate first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client at the clinic. Exhibits Complete the following sentence by The client is at risk for dropdowndue todropdown

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Explanation

A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse plan to include?

Correct Answer is A

Explanation

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