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 B

Explanation

The correct answer is b. Inform the assistive personnel of the client’s weight-bearing status.

Choice A: Assess the client’s incision every 8 hours for the first 48 hours. While it is important to monitor the incision site for signs of infection, the frequency of every 8 hours for the first 48 hours may not be necessary unless specified by the surgeon or the patient’s condition warrants it.

Choice B: Inform the assistive personnel of the client’s weight-bearing status. This is the correct answer. After a total hip arthroplasty, it’s crucial to communicate the client’s weight-bearing status to all members of the healthcare team, including assistive personnel. This helps ensure that everyone is aware of the client’s mobility limitations and can assist the client safely.

Choice C: Instruct the client to cross their legs at the ankles when sitting in a chair. This is not recommended. After a hip arthroplasty, patients are typically advised not to cross their legs to prevent dislocation of the new hip joint.

Choice D: Teach the client’s partner to assist the client to flex the hip at least 120° each hour. This is not recommended. After a hip arthroplasty, patients are typically advised to avoid flexing the hip more than 90 degrees to prevent dislocation of the new hip joint1. Therefore, flexing the hip at least 120° each hour could potentially harm the patient.

A. "Change-of-shift report can be given at the client's bedside.” B. "I can provide client information over the phone if the caller identifies themselves as family.” C. "A client cannot see their medical record because it is considered to be property of the facility.” D. "Access to client information is limited to direct care providers.”

Correct Answer is D

Explanation

Choice A rationale:

Giving change-of-shift report at the client's bedside is not appropriate due to privacy concerns. The client's room is not a private area for discussing their medical information, and other clients or visitors might overhear sensitive details. A more appropriate location, such as a designated nursing station, should be used for shift handoffs.

Choice B rationale:

Providing client information over the phone to callers identifying themselves as family is incorrect. Even if the caller identifies as family, the nurse cannot verify their identity over the phone. Sharing confidential client information without proper verification violates confidentiality policies and can compromise the client's privacy.

Choice C rationale:

Stating that the client cannot see their medical record because it is considered property of the facility is incorrect. Clients have the legal right to access their medical records under the Health Insurance Portability and Accountability Act (HIPAA). While the physical record might be owned by the facility, clients have the right to review their medical information.

Choice D rationale:

Access to client information is limited to direct care providers is the correct statement. Confidentiality requirements dictate that only authorized individuals involved in the client's care, treatment, or payment processes have access to their medical information. This helps protect the client's privacy and ensures that sensitive information is not disclosed to unauthorized parties.

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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

A nurse is reviewing the plan of care for a client following a total hip arthroplasty. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse manager is teaching about confidentiality requirements to the staff. Which of the following staff comments indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is planning discharge care for a client who had a stroke and now has left-sided weakness. Which of the following interventions should the nurse include in the plan of care?

A nurse is receiving report from the assistive personnel (AP) assigned to the nurse's group of clients. Which of the following statements from the AP indicates the client the nurse should assess first?

A nurse walks into the nurses' station and sees several staff members looking at the electronic medical record for a celebrity client on another unit. Which of the following actions should the nurse take first?

A nurse is reviewing a client's clinical pathway upon discharge following hip arthroplasty. Which of the following information can assist the nurse in evaluating the cost effectiveness of the care?

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