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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Notify the charge nurse of the client's request for transfer. This action might be taken eventually, but it is not the first step. The nurse should directly address the client's concerns before escalating the situation to the charge nurse.

Choice B rationale:

Assure the client that their concern has been shared with the staff. Tell the client that future calls will be answered in a timely manner. While it's important to reassure the client, promising timely responses to calls before understanding their expectations might not effectively address the underlying issue. It's better to communicate openly with the client first.

Choice C rationale:

Ask the client to verbalize their expectations. This is the correct choice. By asking the client to express their expectations, the nurse can gather crucial information about the client's concerns and needs. This allows the nurse to address the specific issues that led to the client's dissatisfaction and work toward a resolution that aligns with the client's preferences.

A. Digoxin 1.0 ng/mL. B. WBC 6,000/mm³. C. Platelets 100,000/mm³. D. Serum potassium 4.0 mEq/L.

Correct Answer is C

Explanation

Choice A rationale:

Digoxin is a medication used to treat heart conditions like heart failure and atrial fibrillation. A digoxin level of 1.0 ng/mL is within the therapeutic range (usually 0.5-2.0 ng/mL), indicating that the client's digoxin dosage is appropriate. However, this value doesn't indicate an urgent need for a home visit.

Choice B rationale:

A white blood cell count (WBC) of 6,000/mm³ falls within the normal range (typically 4,500-11,000/mm³). While this value could suggest a stable immune system, it doesn't provide information requiring immediate attention or a home visit.

Choice C rationale:

Platelets are essential for blood clotting. A platelet count of 100,000/mm³ is significantly below the normal range (usually 150,000-450,000/mm³), indicating a risk of bleeding and potentially a serious medical condition. This client is at risk for spontaneous bleeding and requires prompt assessment and intervention, making this choice the correct answer.

Choice D rationale:

A serum potassium level of 4.0 mEq/L falls within the normal range (typically 3.5-5.0 mEq/L). While maintaining electrolyte balance is important, this potassium level doesn't indicate an immediate need for a home visit.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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