Four victims of an automobile accident are brought by the ambulance to the emergency department. Based on the principles of triage, the nurse determines that which patient has the highest priority for treatment?

A sucking chest wound

Absent pedal pulses

Bleeding of head lacerations

An open femur fracture

Answer and Explanation

The Correct Answer is A

A. A sucking chest wound: A sucking chest wound represents an open pneumothorax, which can rapidly compromise ventilation and oxygenation. This is a life-threatening airway and breathing emergency that can quickly lead to hypoxia, respiratory arrest, and death if not immediately managed. According to triage principles, threats to airway and breathing take the highest priority.

B. Absent pedal pulses: Absent pedal pulses indicate compromised circulation to the lower extremities, possibly from vascular injury or compartment syndrome. While urgent assessment and intervention are needed to preserve the limb, it is not immediately life-threatening compared with a compromised airway or breathing.

C. Bleeding of head lacerations: Head laceration bleeding can be significant, but unless associated with neurological compromise or uncontrolled hemorrhage, it generally does not pose an immediate threat to airway or breathing. It is prioritized after life-threatening conditions are addressed.

D. An open femur fracture: An open femur fracture carries risks of hemorrhage and infection, but with controlled bleeding and stable vital signs, it is lower priority than a condition that threatens airway or oxygenation. Management involves stabilization, pain control, and infection prevention after life-threatening emergencies are addressed.

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Correct Answer is C

Explanation

A. Teach about the importance of nutrition after treatment: While nutrition education is important for long-term recovery and maintaining strength, it does not prevent or control acute chemotherapy-induced nausea and vomiting during or immediately after treatment. This intervention alone is insufficient to manage the patient’s severe symptoms.

B. Offer dry crackers and carbonated fluids during the treatments: Small, bland snacks may provide some comfort, but offering them during chemotherapy is unlikely to prevent severe vomiting and diarrhea. The patient’s ability to tolerate oral intake is limited during active emesis, so this is supportive rather than preventive care.

C. Administer prescribed antiemetic 1 hour before the treatments: Prophylactic administration of antiemetics is the most effective strategy for controlling chemotherapy-induced nausea and vomiting. Giving the medication before treatment allows peak drug levels to coincide with chemotherapy exposure, reducing the severity and frequency of emesis and improving patient comfort.

D. Have the patient eat large meals when nausea is not present: Large meals can be difficult to tolerate and may exacerbate nausea or vomiting. Smaller, frequent meals are generally recommended for patients with chemotherapy-induced gastrointestinal upset, making this approach less effective than timely antiemetic therapy.

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

Explanation

Rationale for Correct Answers:

Notify the provider: The client’s sudden change in level of consciousness, restlessness, irritability, and new headache after receiving alteplase indicates a potentially serious complication. Immediate notification of the healthcare provider is critical to ensure prompt evaluation, possible imaging, and interventions to prevent further neurological deterioration.
Increased intracranial pressure: The new neurological symptoms, decreased responsiveness, irritability, and headache, suggest rising intracranial pressure (ICP), likely secondary to cerebral edema following ischemic stroke and thrombolytic therapy. Increased ICP can compromise cerebral perfusion and oxygenation, leading to rapid neurological decline. Early recognition and intervention are essential to prevent permanent damage or herniation.

Rationale for Incorrect Answers:

Encourage the client to rest quietly: This delays emergency intervention. The symptoms indicate possible intracranial bleeding, not simple fatigue.
Document the findings and continue routine monitoring: Routine monitoring is inappropriate when there is a sudden neurologic change after thrombolytic therapy. This is not stable, it is a potential life-threatening complication.
Hypoglycemia: This can cause altered LOC, but there is no evidence in the scenario suggesting low blood glucose. Additionally, the new severe headache strongly suggests increased ICP.
Anxiety: This does not cause decreased level of consciousness or focal neurologic decline.

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Four victims of an automobile accident are brought by the ambulance to the emergency department. Based on the principles of triage, the nurse determines that which patient has the highest priority for treatment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with metastatic cancer of the colon experiences severe vomiting and diarrhea following each administration of chemotherapy. Which nursing intervention is most effective?

Correct Answer is C

Explanation

Based on the information in the electronic health record, complete the sentences using the drop-down lists. The nurse's initial action after assessing the patient at 1600 is todropdown. The nurse suspects the client's new symptoms are related todropdown.

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

Explanation

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Four victims of an automobile accident are brought by the ambulance to the emergency department. Based on the principles of triage, the nurse determines that which patient has the highest priority for treatment?