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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

Tilting the head may increase aspiration risk by altering the normal swallowing mechanism. Proper positioning supports safe swallowing and minimizes the risk of aspiration-related complications in dysphagia.

Choice B rationale

Upright sitting posture enhances gravity-assisted swallowing, reduces aspiration risk, and supports proper esophageal clearance, essential in safe feeding practices for clients with dysphagia.

Choice C rationale

Using a syringe for liquid administration increases aspiration risk, as it bypasses normal swallowing reflexes and may cause choking. Dysphagia management prioritizes controlled, natural swallowing methods.

Choice D rationale

Resting before meals may reduce fatigue but doesn't directly address safe swallowing practices. Positioning and feeding techniques are more critical in minimizing aspiration risks in clients with dysphagia.

A. Wash hands with cold water for at least 15 seconds and dry with a towel. B. Wash hands with soap and warm water for at least 10 seconds and air dry. C. Wash hands with soap and warm water for at least 15 seconds and then dry hands with a clean paper towel. D. Wash hands with only water and dry with a clean paper towel.

Correct Answer is C

Explanation

Choice A rationale

Washing hands with cold water is less effective for removing pathogens compared to warm water. Warm water opens pores and enhances soap’s efficacy in breaking down oils and debris. Duration is also insufficient.

Choice B rationale

Washing for 10 seconds does not provide sufficient time for thorough microbial removal as evidence supports 15-20 seconds for optimal hand hygiene. Air drying increases the risk of recontamination and bacterial persistence.

Choice C rationale

Using soap and warm water for at least 15 seconds effectively removes microorganisms, reducing cross-infection. Drying with clean paper towels prevents bacterial growth and contamination compared to air drying or reused cloths.

Choice D rationale

Washing with water alone lacks the surfactant action of soap, which emulsifies oils and debris carrying bacteria. Drying with a clean towel prevents contamination but cannot compensate for soap absence.

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Which client should receive immediate intervention based on the following details?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is updating a plan of care after an evaluation of a client who has dysphagia. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

Which of the following is correct about a nurse hygiene?

Correct Answer is C

Explanation

A nurse in a provider’s office is assessing the motor skill development of a 15-month-old toddler during a well-child visit. Which of the following gross motor skills should the nurse expect?

A nurse is teaching a group of assistive personnel about the expected integumentary changes in older adult clients. Which of the following findings should the nurse include in the teaching?

A nurse is planning to administer several medications to a client through a nasogastric (NG) tube. Which of the following actions should the nurse take?

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?

A nurse is assessing a client who is receiving oxygen therapy. Which of the following findings should the nurse identify as a late manifestation of hypoxia?

A nurse is documenting client care. Which of the following entries should the nurse identify as an example of implementation of client care?

A charge nurse is preparing a teaching session for a group of newly licensed nurses about the general principles of immunity. Which of the following statements should the nurse plan to include in the teaching?

A community health nurse is teaching a group of clients about first aid for different types of wounds. Which of the following client statements indicates an understanding of the teaching?