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","C","D","E"]
Explanation
The correct answers are choices A, C, D, and E:
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Choice A rationale: The right to be treated with respect and dignity is a fundamental client right in any healthcare setting, including long-term care facilities. This right ensures that clients receive care in a compassionate and respectful manner.
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Choice B rationale: Full access to the facility is not a standard client right in long-term care facilities. Access to certain areas might be restricted for safety reasons or to maintain privacy.
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Choice C rationale: The right to refuse medications is an essential aspect of client autonomy, allowing clients to make informed decisions about their care. It is important to address this right during orientation.
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Choice D rationale: The right to leave regardless of provider recommendations is another aspect of client autonomy. Clients should be informed of their right to refuse care or leave the facility if they wish, even if it goes against the advice of healthcare providers.
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Choice E rationale: The right to be fully informed of their health conditions is a crucial aspect of client autonomy and transparency in healthcare. Clients should be aware of their health status and treatment options to make informed decisions about their care.
In conclusion, when conducting an orientation class for new clients and their families at a long-term care facility, the nurse should address the rights to be treated with respect and dignity, refuse medications, leave the facility (even if it is against the recommendations of healthcare providers), and be fully informed of their health conditions.
Correct Answer is A
Explanation
Choice A rationale:
Reminding the staff members that viewing the electronic medical record of a celebrity client without proper authorization is a breach of confidentiality is the immediate action required in this situation. It addresses the ethical and legal concerns related to patient privacy and ensures that the staff members are reminded of their professional responsibilities.
Choice B rationale:
Discussing the issue with the nurse manager is a step that can be taken after addressing the immediate breach of confidentiality. While involving the manager is important for handling the situation more comprehensively, the first priority is to stop the unauthorized access.
Choice C rationale:
Requesting an administrative restriction on the client's record access is an option that can be considered, but it may not be the first step to take. Before implementing such a restriction, the breach of confidentiality should be addressed directly with the staff members involved.
Choice D rationale:
Preparing a memo for the facility ethics committee is not the initial action to take in response to the breach of confidentiality. This step might be appropriate for addressing systemic issues or policy changes related to confidentiality breaches, but it doesn't directly address the immediate situation at hand.
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