Which client should receive immediate intervention based on the following details?
Client with a sucking chest wound, conscious, blood pressure 88/58 mm Hg, heart rate 115/min, and red tag observed.
Client with a significant penetrating head wound, unconscious with irregular breathing pattern, and black tag observed.
Client with superficial lacerations to the left arm and left lower leg, occlusive dressing in place, tearful, blood pressure 118/78 mm Hg, and green tag observed.
Client with closed left lower leg injury, air cast in place, pain reported as 9 on a 0 to 10 numeric pain scale, and yellow tag observed.
The Correct Answer is A
Choice A rationale
Sucking chest wounds impair oxygenation, posing a direct threat to life. Signs of shock (88/58 mm Hg, heart rate 115/min) demand immediate intervention. Red tag classification reflects life-threatening but treatable conditions needing priority care.
Choice B rationale
Significant penetrating head wounds with irregular breathing indicate brainstem damage, which usually leads to poor outcomes. Black tag assignment denotes expectant management due to un-survivable injuries.
Choice C rationale
Superficial lacerations with stable vitals (118/78 mm Hg) and occlusive dressing in place ensure no life-threatening issues. Green tag indicates minimal care urgency, requiring no immediate intervention.
Choice D rationale
Closed lower leg injuries causing severe pain do not compromise airway, breathing, or circulation. Yellow tag classification reflects delayed medical needs, prioritizing resources for more critical cases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Placing the client on their side with their head forward ensures airway patency by promoting drainage of secretions and reducing the risk of aspiration during a seizure episode. This position prioritizes the client’s safety and ventilation.
Choice B rationale
Administering anticonvulsants is essential for seizure management but is not the initial priority during an active seizure. This action occurs after ensuring the client’s immediate safety and stability to control recurrent seizures.
Choice C rationale
Timing the seizure provides important diagnostic data but does not address the immediate safety needs of the client. Prioritizing airway management and reducing aspiration risk is more critical during an active seizure.
Choice D rationale
Loosening the client’s gown and allowing movement does not adequately protect the airway or mitigate aspiration risks. While ensuring comfort is important, this measure is secondary to positioning the client properly.
Correct Answer is A
Explanation
Choice A rationale
Applying clean dressings over blood-saturated ones helps maintain sterility and pressure, minimizing further bleeding while reducing the risk of contamination or infection.
Choice B rationale
Hydrogen peroxide can delay healing by causing tissue damage through cytotoxic effects on fibroblasts and keratinocytes.
Choice C rationale
Removing objects from penetrating wounds can worsen internal injuries or cause hemorrhage, as the object may be tamponading bleeding vessels.
Choice D rationale
Placing the affected area in a dependent position increases venous pressure, exacerbating swelling and potentially worsening bleeding or tissue damage.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.