A nurse in an emergency department is admitting clients following an earthquake. The emergency disaster plan has been implemented due to the anticipated arrival of a large number of casualties. Which of the following clients should the nurse recommend the provider evaluate first?
A client who has a penetrating head injury and respiratory rate of 4/min.
A client who has a comminuted fracture of the femur.
A client who has a 15.2-cm (6-in) laceration to the scalp with clotted blood visible.
A client who has a sucking chest wound.
The Correct Answer is D
Choice A rationale:
A client who has a penetrating head injury and a respiratory rate of 4/min requires immediate attention due to the critical nature of the head injury and the dangerously low respiratory rate. However, in an emergency situation like this, the priority would be a condition that could be rapidly fatal if not addressed promptly.
Choice B rationale:
A client with a comminuted fracture of the femur has a serious injury that requires assessment and treatment, but it is not an immediately life-threatening condition. It falls lower in the priority compared to conditions that directly impact respiratory and cardiovascular function.
Choice C rationale:
A client with a 15.2-cm laceration to the scalp with clotted blood visible also requires attention, but it is not as time-sensitive as a life-threatening condition. Controlling bleeding and cleaning the wound can be addressed after addressing more critical cases.
Choice D rationale:
Correct. A client with a sucking chest wound has a high risk of tension pneumothorax, a condition where air accumulates in the pleural space, leading to lung collapse and compromised circulation. This condition can be rapidly fatal. Immediate intervention is required to seal the wound and prevent further air from entering the pleural space.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The child having red fissures at the corners of the mouth is not the priority finding. While this could indicate a nutritional deficiency, such as vitamin B2 (riboflavin) deficiency, the presence of bruises on the child's legs raises more immediate concerns related to potential physical abuse or safety issues.
Choice B rationale:
The child having several small bruises on both legs is the priority finding. Bruising on a school-age child could indicate physical abuse or an unsafe living environment. Ensuring the child's safety and well-being takes precedence over other findings. Assessing the nature, pattern, and explanation for the bruises is crucial.
Choice C rationale:
The child sleeping for about 13 hours each night is not the priority finding in this scenario. While sleep patterns are important, the potential for physical abuse and safety concerns associated with the bruises takes precedence.
Choice D rationale:
The child not regularly attending school is a concern, but it is not the priority finding when compared to the possibility of physical abuse indicated by the bruises. Both issues need to be addressed, but ensuring the child's immediate safety is the primary focus.
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
“A client who is in balanced skeletal traction.” This client requires specialized orthopedic knowledge to manage the traction and monitor for complications. A nurse without orthopedic experience may not be familiar with the care required.
Choice B rationale:
“A client who had a total hip arthroplasty 3 days ago.” This client is likely to require specialized post-operative care, including pain management, mobility assistance, and monitoring for complications such as infection or dislocation. These tasks typically require specific orthopedic training.
Choice C rationale:
“A client who has a fractured femur with a new cast.” This client will require specialized care to manage the cast, monitor for complications such as compartment syndrome, and provide pain management. These tasks typically require specific orthopedic training.
Choice D rationale:
“A client who had a right above-the-knee amputation 24 hours ago.” This is the correct answer. While this client will require post-operative care, the care is likely to be similar to the post-operative care provided on a medical unit, such as pain management, wound care, and monitoring for complications. Therefore, a nurse from a medical unit could likely provide appropriate care for this client.
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