A nurse in an emergency department is triaging clients following an external natural disaster. Which of the following clients should the nurse identify to receive care first?
A client who has an open fracture of the tibia and reports pain as 5 on a scale of 0 to 10
A client who has suspected appendicitis and reports severe lower right abdominal pain
A client who has a penetrating head wound and fixed pupils
A client who has flail chest and a respiratory rate of 32/min
The Correct Answer is D
A. A client who has an open fracture of the tibia and reports pain as 5 on a scale of 0 to 10: While the open fracture requires prompt attention to prevent infection and manage pain, it is not immediately life-threatening. This client can be treated after more critical, unstable patients.
B. A client who has suspected appendicitis and reports severe lower right abdominal pain: Suspected appendicitis is urgent but not immediately life-threatening unless complications like rupture occur. This client’s condition is lower priority compared to airway or breathing compromise.
C. A client who has a penetrating head wound and fixed pupils: Fixed pupils suggest a non-survivable brain injury. In a mass casualty or disaster triage situation, this client is considered expectant and would not receive immediate intervention.
D. A client who has flail chest and a respiratory rate of 32/min: Flail chest with increased respiratory rate indicates respiratory compromise and potential hypoxia, which is life-threatening. Airway and breathing take priority, so this client requires immediate intervention to stabilize breathing and prevent rapid deterioration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A 14-year-old child who eats small but frequent meals throughout the day: This is an appropriate intervention for gastroesophageal reflux, as smaller, more frequent meals reduce gastric distention and minimize reflux episodes. No revision to the plan of care is needed for this child.
B. A 16-year-old child who takes their proton pump inhibitor 30 min before meals: Administering proton pump inhibitors before meals is correct because these medications are most effective when taken prior to food intake, allowing for optimal acid suppression. The current plan aligns with best practice.
C. A 6-year-old child who underwent a Nissen fundoplication and is tolerating a full liquid diet: Progressing to a full liquid diet after Nissen fundoplication is appropriate and indicates the child is tolerating postoperative dietary advancement. The plan of care is appropriate and requires no changes.
D. A 4-month-old child who is experiencing weight loss: Weight loss in an infant with gastroesophageal reflux is concerning and indicates inadequate nutrition or complications. The plan of care should be revised to address feeding adequacy, possible medical interventions, and close monitoring of growth and hydration status.
Correct Answer is ["A","B","E","G"]
Explanation
A. Obtain a brain natriuretic peptide (BNP) test: BNP is a marker of heart failure and is indicated given the client’s new-onset dyspnea, crackles, and S3/S4 heart sounds. Measuring BNP helps assess for possible acute decompensated heart failure following surgery.
B. Obtain a complete blood count: A CBC helps identify infection, anemia, or other hematologic changes that could contribute to dyspnea, tachypnea, or hypoxia in the postoperative client. The client’s fever and tachycardia warrant this assessment.
C. Request respiratory therapy for intubation: Intubation is not immediately indicated as the client is still alert, maintaining oxygen saturation of 92% on supplemental oxygen. Less invasive diagnostics and interventions are prioritized first.
D. Obtain a STAT MRI: MRI is not the first-line diagnostic tool for acute dyspnea and postoperative cardiopulmonary assessment. It is not indicated in emergent evaluation of pulmonary or cardiac complications.
E. Obtain ABGs: Arterial blood gases are important to assess oxygenation, ventilation, and acid-base status given the client’s tachypnea, hypoxemia, and sudden respiratory distress.
F. Prepare the client for cardiac catheterization: Cardiac catheterization is invasive and not the immediate priority. Initial noninvasive assessment should guide the need for further intervention.
G. Obtain a chest x-ray: A chest x-ray is indicated to assess for pulmonary edema, pleural effusion, or other cardiopulmonary complications in a postoperative client presenting with dyspnea, crackles, and hypoxia.
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