Which client should the nurse prioritize as needing emergent treatment assuming no other injuries are present except the ones outlined below?
A client with a blunt chest trauma with some difficulty breathing
A client with confusion
A client with a sore neck who was immobilized in the field on a backboard with a cervical collar
A client with a possible fractured tibia with adequate pedal pulses
The Correct Answer is A
A. A client with a blunt chest trauma with some difficulty breathing: Blunt chest trauma with respiratory difficulty indicates pneumothorax or pulmonary contusion. These conditions can deteriorate rapidly if not treated immediately. Airway and breathing always take priority in emergency triage. Early management prevents respiratory failure and severe hypoxia.
B. A client with confusion: Confusion suggests neurological or metabolic issues, but there is no indication of airway or breathing compromise. The condition requires prompt evaluation but does not present the same immediate danger as respiratory distress. The client is more stable and can be safely reassessed once life-threatening issues are addressed.
C. A client with a sore neck who was immobilized in the field on a backboard with a cervical collar: The client may have a spinal injury, but immobilization already provides protection from further harm. There is no evidence of airway or breathing instability that would elevate the urgency. This allows the client to wait safely while higher-priority conditions are treated.
D. A client with a possible fractured tibia with adequate pedal pulses: A tibial fracture is not life-threatening when distal pulses are present, indicating that circulation to the limb is intact. The client is stable and can safely wait while emergent issues are managed first. Orthopedic injuries without vascular compromise pose minimal immediate risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Hyperphosphatemia, a change in the LOC, and dysrhythmias: Hyperphosphatemia is more a chronic issue in kidney disease, not an acute dialysis complication. While LOC changes and dysrhythmias can occur, the combination is incomplete for typical dialysis complications.
B. Dysrhythmias, hypertension, and a change in the LOC: Hypertension is less common during dialysis; hypotension is more frequently observed due to fluid removal. This combination does not reflect the most common acute complications.
C. Hypertension, muscle cramping, and nausea: Muscle cramping and nausea are relevant, but hypertension is not typical during dialysis. Hypotension, not elevated blood pressure, is a more frequent acute complication.
D. Muscle cramping, dysrhythmias, and hypotension: These are the most common complications during dialysis. Hypotension results from rapid fluid removal, muscle cramping occurs due to fluid and electrolyte shifts, and dysrhythmias can arise from electrolyte imbalances, particularly potassium changes. Monitoring for these ensures client safety.
Correct Answer is A
Explanation
A. Rapid pulse and prolonged capillary refill: A rapid pulse combined with delayed capillary refill strongly suggests poor perfusion and early hypovolemic shock. These findings indicate that the body is compensating for volume loss by increasing heart rate and redirecting blood to vital organs. Capillary refill slows as peripheral circulation decreases.
B. Increased BP with narrowed pulse pressure: Increased blood pressure does not align with internal bleeding, as hypovolemia typically causes the pressure to fall rather than rise. Narrowed pulse pressure can occur in shock, but pairing it with elevated BP makes internal hemorrhage less likely.
C. Sudden diaphoresis: Diaphoresis can occur with pain, anxiety, fever, or sympathetic activation, making it nonspecific. While it may accompany early shock, it does not reliably indicate internal bleeding on its own. The absence of other hemodynamic changes limits its diagnostic value. More definitive perfusion changes would be expected in hemorrhage.
D. Increasing urinary output: Rising urine output generally reflects adequate renal perfusion and fluid status, which contradicts signs of internal hemorrhage. As bleeding progresses, urine output typically declines due to reduced circulating volume. An increase suggests stability rather than deterioration.
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