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 A

Explanation

Choice A rationale

Asking clients to describe their feelings encourages them to verbalize concerns, which reduces anxiety by clarifying fears and fostering nurse-client communication in preparation for emotional support.

Choice B rationale

Informing clients that others have not faced problems invalidates individual feelings and does not address the specific anxiety source, potentially worsening emotional distress instead.

Choice C rationale

Discussing surgeon competency redirects focus from client emotions to unrelated factors, failing to provide targeted support for expressed anxiety about surgery.

Choice D rationale

Questioning why a client experiences anxiety can feel accusatory or judgmental, thereby escalating stress rather than fostering an empathetic understanding for therapeutic communication.

A. Perform palpation after auscultation. B. Listen for 5 minutes before documenting absent bowel sounds. C. Perform auscultation immediately after the client has consumed a meal. D. Document shiny, taut skin as an expected finding.

Correct Answer is B

Explanation

Choice A rationale

Palpation after auscultation minimizes alterations in bowel sounds caused by palpation. Listening first ensures the most accurate assessment of bowel activity before external manipulation potentially disrupts peristalsis.

Choice B rationale

Listening for 5 minutes ensures accurate detection of absent bowel sounds, which require prolonged assessment to confirm. Normal bowel sounds typically occur every 5-30 seconds, necessitating extended listening before documenting absence.

Choice C rationale

Auscultating after a meal could result in increased bowel sounds due to digestion, which may not represent baseline activity. Waiting allows for a more accurate assessment of the client’s normal bowel sounds.

Choice D rationale

Shiny, taut skin on the abdomen is indicative of ascites or edema and is not an expected finding. Such documentation overlooks the need for further assessment of potential fluid accumulation.

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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 caring for a client who expresses anxiety about an upcoming surgery. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is preparing to perform a routine abdominal assessment for a client. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client in the emergency department. Which action should the nurse take based on the client’s medication administration record at 1130?

A nurse in a provider’s office is assessing a client who reports a decrease in the effectiveness of their arthritis medication. Which of the following client information should the nurse identify as a contributing factor to the decrease in the medication’s effectiveness?

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 caring for a 45-year-old male client in the emergency department. Exhibits The nurse should prioritize which action based on the client's assessment findings?

A nurse is caring for a client who has a nonpalpable skin lesion that is less than 0.5 cm (0.2 in) in diameter. Which of the following terms should the nurse use to document this finding?

Which prescription should the nurse clarify with the provider prior to administration?

A nurse is preparing to transfer a client from a chair to the client’s bed. The client can bear partial weight and has upper body strength. Which of the following devices should the nurse use to transfer the client?

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings should the nurse identify as an indication of a possible catheter occlusion?