The nurse should identify that Client 1 requires priority care due to which of the following reasons?

The client has severe but survivable injuries.

The client has minor injuries requiring immediate care.

The client has non-life-threatening injuries but requires follow-up care.

The client has injuries that do not require urgent attention.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Severe but survivable injuries demand immediate care to stabilize critical functions like airway, breathing, and circulation. Prioritizing care ensures better survival outcomes, especially with red tag cases requiring prompt medical intervention.

Choice B rationale

Minor injuries do not threaten life or major functions, so they do not require immediate care. Patients with minor issues are generally green-tagged and can wait without significant adverse outcomes.

Choice C rationale

Non-life-threatening injuries needing follow-up care may have minimal short-term risks, making them less urgent. Such cases often align with yellow tag classifications for priority but non-immediate attention.

Choice D rationale

Injuries without urgent attention lack immediate risk to life or function. These cases can afford to wait without compromising patient outcomes, especially under mass casualty triage protocols.

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Correct Answer is C

Explanation

Answer and explanation

The correct answer is Choice C.

Choice A rationale

Procedures can be canceled even after consent. This statement disregards the client’s autonomy and right to change their decision regarding the planned surgery.

Choice B rationale

Encouraging immediate surgery does not respect the client’s doubts. This approach may undermine trust and does not address the client’s need for reassurance or clarification.

Choice C rationale

The surgeon is the most qualified to address the client’s concerns. Providing accurate, detailed explanations respects the client’s autonomy and supports informed decision-making about the surgery.

Choice D rationale

Nurses are not responsible for explaining surgical procedures. This explanation should be provided by the surgeon to ensure clarity, accuracy, and client understanding of the medical details.

A. Attach a probe carefully to the client’s finger. B. Apply a sensor pad to the client’s forehead. C. Secure a probe to one of the client’s toes. D. Obtain a pulse oximetry reading using an alternative site.

Correct Answer is B

Explanation

Choice A rationale

Peripheral edema may impede accurate readings due to compromised capillary blood flow in fingers. Thickened toenails may further reduce sensor reliability, leading to errors in oxygen saturation measurement.

Choice B rationale

The forehead is ideal for pulse oximetry in patients with peripheral edema. It provides a reliable alternative site with consistent capillary blood flow and is unaffected by thickened nails or peripheral circulation issues.

Choice C rationale

Peripheral edema affects capillary blood flow in toes, and thickened toenails obstruct sensor attachment, leading to unreliable and inaccurate oxygen saturation readings for clinical assessment.

Choice D rationale

While alternative sites might be useful, the forehead offers a proven, optimal placement for reliable oxygen saturation readings in cases of peripheral edema and other extremity-related complications.

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The nurse should identify that Client 1 requires priority care due to which of the following reasons?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting a client who signed an informed consent form for surgery but has since expressed doubts about the need for surgery. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

A nurse is preparing to obtain the oxygen saturation of a client who has peripheral edema and thickened toenails. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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