The nurse is triaging a group of clients in the emergency department. Which client should be assessed first?

A client with a burn on their forearm sustained from boiling water

A client with a right ankle fracture unable to place any weight on it

A client with severe abdominal pain who is pale and diaphoretic

A client with a head laceration being controlled with pressure

Answer and Explanation

The Correct Answer is C

A. A client with a burn on their forearm sustained from boiling water: While burns require assessment and care, a forearm burn without signs of systemic compromise is not immediately life-threatening and can wait after more urgent cases.

B. A client with a right ankle fracture unable to place any weight on it: An isolated fracture causes pain and limited mobility but is not life-threatening, making it lower priority in triage compared to clients with potential systemic compromise.

C. A client with severe abdominal pain who is pale and diaphoretic: Pallor and diaphoresis indicate possible shock or serious internal pathology. This client is at highest risk for rapid deterioration and requires immediate assessment and intervention.

D. A client with a head laceration being controlled with pressure: If bleeding is controlled and the client is stable, this is urgent but not immediately life-threatening, so the client can be assessed after those showing signs of shock or systemic compromise.

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Correct Answer is B

Explanation

A. Measuring the client's vital signs: Vital signs are part of the physical assessment, not the general survey. They provide objective data but are collected separately from the initial observational overview.

B. Observing the client's body stature: The general survey involves an overall observation of the client’s physical appearance, including body stature, posture, gait, and apparent age. These observations help the nurse form a baseline impression of the client’s health.

C. Auscultating lung sounds: Auscultation is a specific component of the focused physical assessment, not part of the general survey. It requires using a stethoscope and detailed evaluation of specific body systems.

D. Prioritizing client's needs: Prioritization occurs after assessment and data collection. While essential for care planning, it is not a component of the general survey, which is primarily observational.

A. Request that handouts be prepared for the client. B. Provide information with graphics and photographs. C. Ask a family member to translate instructions. D. Use a trained medical interpreter for translation.

Correct Answer is D

Explanation

A. Request that handouts be prepared for the client: While handouts can supplement teaching, simply providing written materials may not ensure understanding, especially if the client has limited literacy or language proficiency. Handouts alone are insufficient for accurate comprehension.

B. Provide information with graphics and photographs: Visual aids can enhance understanding, but they may not fully convey complex medical information or instructions. Relying solely on visuals can lead to misinterpretation without proper translation.

C. Ask a family member to translate instructions: Using a family member for translation can risk inaccurate or incomplete communication and may compromise confidentiality. Medical terminology may be misunderstood, which can affect safe care.

D. Use a trained medical interpreter for translation: A trained medical interpreter ensures accurate, culturally appropriate communication and helps the client fully understand the teaching. This approach supports informed decision-making and patient safety.

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The nurse is triaging a group of clients in the emergency department. Which client should be assessed first?

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Naxlex Comprehensive Predictor Exams

Which is included in the general survey?

Correct Answer is B

Explanation

A nurse educates a client with limited English-speaking skills about their disease. What action should the nurse take to ensure the client is able to understand the teaching?

Correct Answer is D

Explanation

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