A nurse in the emergency department is performing triage for a group of clients who were in a train crash. Which of the following clients should the nurse tag as emergent?
A client who has an open fracture of the femur
A client who has periorbital ecchymosis
A client who has a deep partial thickness burn on the lower extremities
A client who has an asymmetrical thorax
The Correct Answer is D
Rationale for A: An open fracture of the femur is serious and requires prompt treatment, but it does not typically indicate an immediate life threat compared to other conditions.
Rationale for B: Periorbital ecchymosis can indicate facial trauma, but it is not necessarily life-threatening and would not be prioritized as emergent.
Rationale for C: A deep partial thickness burn on the lower extremities is significant and requires treatment, but unless the burn covers a large area or is complicated by other factors, it is not the most critical issue compared to respiratory or cardiovascular threats.
Rationale for D: An asymmetrical thorax may suggest a possible pneumothorax or other significant respiratory issue, which could lead to respiratory distress or failure. This client should be tagged as emergent due to the potential for rapid deterioration.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
- A: This client requires initial teaching, which is typically the responsibility of a registered nurse due to the educational aspect and the need to assess the client's understanding.
- B: Administering an enema is a task that falls within the scope of practice for a licensed practical nurse and does not require the advanced assessment skills of a registered nurse.
- C: Developing an initial plan of care involves comprehensive assessment and critical thinking, which are responsibilities of a registered nurse.
- D: A client transferring from the CCU after a myocardial infarction would require close monitoring and assessment, which are beyond the scope of practice for a licensed practical nurse.
Correct Answer is D
Explanation
A. Referring the adult child to the primary care provider might not immediately address the information needed.
B. Directing the adult child to speak solely with the mother might not be the most helpful approach to gather necessary information.
C. Inviting the adult child to specify what information they seek is not correct as they would have to get this information from their mother or their mother wil have to consent.
D. It is the role of the nurse to inform the child that they cannot disclose that information since patient confidentiality is a priority.
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