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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Orange slices. Vitamin C-rich foods like oranges enhance the absorption of nonheme iron, which is found in plant-based sources such as legumes, leafy greens, and fortified cereals. This is especially important for vegetarians who rely on nonheme iron sources.
B. Boiled eggs. While eggs contain iron, they also contain phosphoproteins that can actually inhibit iron absorption. They do not enhance the absorption of nonheme iron and are not ideal for this purpose.
C. Mixed nuts. Nuts provide a source of nonheme iron but do not significantly enhance iron absorption. They lack vitamin C, which is essential for improving nonheme iron bioavailability.
D. Cheddar cheese. Dairy products like cheese contain calcium, which can inhibit iron absorption. They are not recommended to enhance iron uptake, particularly when consuming nonheme iron.
Correct Answer is C
Explanation
A. Place the client in a side-lying position for the procedure. Paracentesis is typically performed with the client in a high-Fowler’s or upright position, allowing fluid to collect in the lower abdomen for easier drainage.
B. Administer a low-volume hypertonic enema the night before the procedure. An enema is not required for a paracentesis, as the procedure involves the peritoneal cavity, not the bowel.
C. Weigh the client before and after the procedure. Weighing the client helps assess the amount of fluid removed and monitor for fluid shifts. It is a key part of pre- and post-procedural care to evaluate the effectiveness of the intervention.
D. Ensure the client has a full bladder just prior to the procedure. A full bladder increases the risk of injury during needle insertion. The bladder should be emptied before the procedure to prevent accidental puncture.
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