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 ["A","D","E"]
Explanation
A. "This medication can cause nausea and drowsiness.": Gastrointestinal upset and central nervous system effects such as drowsiness are common early adverse effects of lithium therapy. Clients should be informed so they can recognize mild side effects versus signs of toxicity.
B. "You will be placed on a low-sodium diet while taking this medication.": Lithium requires a consistent, not low, sodium intake. Low sodium can increase lithium reabsorption in the kidneys, raising the risk of toxicity. Emphasizing a consistent dietary sodium intake is important rather than restricting sodium.
C. "Blurred vision is an expected adverse effect of this medication.": Blurred vision is not an expected side effect of lithium and may indicate toxicity or another ocular issue. Clients should report changes in vision promptly rather than consider them routine.
D. "This medication can cause weight gain.": Weight gain is a known side effect of lithium therapy due to fluid retention and metabolic changes. Clients and caregivers should be aware to monitor weight and maintain healthy lifestyle practices.
E. "It will take at least a week before this medication reaches a therapeutic level.": Lithium requires several days to reach a therapeutic blood level, and effects on mood stabilization are gradual. Educating the client about delayed onset helps set realistic expectations and encourages adherence.
Correct Answer is A
Explanation
A. Ask the client to rate their pain on a scale of 0 to 10: Pain assessment is the first step in managing pain effectively. Using a standardized pain scale helps determine the severity, effectiveness of the previous dose, and guides subsequent interventions or medication adjustments.
B. Request a prescription for an opioid pain medication for the client: While opioids may be appropriate for breakthrough pain, the nurse must first assess the current pain level and response to prior medication before requesting additional prescriptions. Immediate escalation is premature without assessment.
C. Report this client finding to the provider: Reporting is important if pain persists despite interventions, but initial assessment and documentation of pain severity should precede notifying the provider to provide accurate information.
D. Administer an additional dose of ibuprofen to the client: Administering another dose without verifying timing, maximum daily dosage, or assessing pain response could risk overdose or toxicity. Pain assessment must guide safe medication administration.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.