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. "Empty the drainage bag every 12 hours.": Urine should be emptied regularly, but not on a fixed 12-hour schedule. The focus is on preventing backflow and maintaining sterility, so the bag should be emptied when it is two-thirds full or as needed, rather than strictly every 12 hours.
B. "Irrigate the indwelling urinary catheter once per shift.": Routine irrigation is not recommended for preventing catheter-associated urinary tract infections (CAUTIs) and can introduce pathogens or cause trauma. Irrigation should only be performed if specifically indicated for obstruction or provider order.
C. "Apply a topical antimicrobial ointment as part of routine catheter care.": Routine application of antimicrobial ointment is not recommended and does not prevent CAUTIs. Proper hygiene and sterile technique are more effective in infection prevention than topical agents.
D. "Keep the drainage bag below the level of the bladder.": Maintaining the drainage bag below the bladder prevents backflow of urine, which is a major risk factor for introducing bacteria into the urinary tract. This simple intervention is a key measure in reducing catheter-associated urinary tract infections.
Correct Answer is B
Explanation
A. "I will report equipment with three-prong electric plugs as a fire hazard.": Three-prong plugs are designed for safety, providing grounding to prevent electrical fires. Reporting them as hazards indicates a misunderstanding of proper electrical safety.
B. "If I see a fire, I should try to remove the client from the room first.": Ensuring client safety is the top priority during a fire. Removing clients from immediate danger follows the first step of the RACE protocol (Rescue, Alarm, Contain, Extinguish), demonstrating correct understanding of fire response.
C. "I should place equipment in front of the emergency exit to prop it open.": Blocking emergency exits is a serious fire safety violation. Exits must remain clear at all times to allow rapid evacuation.
D. "I should sweep the fire extinguisher from side to side before squeezing the handle.": The correct sequence is to pull the pin, aim at the base of the fire, squeeze the handle, and then sweep side to side. Sweeping before squeezing would render the extinguisher ineffective.
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