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 D
Explanation
Choice A rationale:
The National League for Nursing (NLN) focuses on nursing education standards and resources for nursing faculty. While it could provide useful insights, it's not the primary resource for policy creation related to procedures like catheter insertion.
Choice B rationale:
The American Academy of Nursing (AAN) is a professional organization that promotes leadership and education within nursing. While it might offer recommendations, it's not the primary resource for policy related to procedural changes in clinical settings.
Choice C rationale:
The Agency for Healthcare Research and Quality (AHRQ) is involved in research and quality improvement initiatives in healthcare. While it could provide evidence-based practices, it's not the primary source for policies specific to nursing procedures.
Choice D rationale:
The State Nurse Practice Act (NPA) outlines the scope of nursing practice within a particular state. It governs what nurses are allowed to do, including procedures like catheter insertion. The NPA ensures that nursing actions are within legal and regulatory bounds, making it the most relevant resource for creating a policy about catheter insertion.
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
“Auscultate the client’s bowel sounds.” While auscultating bowel sounds can provide information about the client’s gastrointestinal function, it is not the priority assessment for a client who has been vomiting and experiencing diarrhea for the past 6 hours.
Choice B rationale:
“Measure the client’s temperature.” Measuring the client’s temperature can help identify if the client has an infection, which could be causing the vomiting and diarrhea. However, it is not the priority assessment in this situation.
Choice C rationale:
“Check the client’s urine specific gravity.” Checking the client’s urine specific gravity can provide information about the client’s hydration status. However, it is not the priority assessment for a client who has been vomiting and experiencing diarrhea for the past 6 hours.
Choice D rationale:
“Obtain the client’s serum potassium level.” This is the correct answer. Prolonged vomiting and diarrhea can lead to significant loss of electrolytes, including potassium. A low potassium level (hypokalemia) can have serious effects, including cardiac arrhythmias. Therefore, obtaining the client’s serum potassium level is the priority assessment.
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