A nurse in the emergency department is triaging clients following a mass casualty event. The nurse should identify which of the following clients as emergent?
A client who reports flank pain radiating to the groin
A client who has multiple fractures
A client with partial thickness burns to both hands
A client who has a punctured femoral artery
The Correct Answer is D
A. A client who reports flank pain radiating to the groin: This could indicate renal colic or a kidney stone. While painful and concerning, it is not as immediately life-threatening as severe hemorrhage.
B. A client who has multiple fractures: Multiple fractures are serious but may not be as immediately life-threatening as severe hemorrhage or airway compromise.
C. A client with partial thickness burns to both hands: While painful and needing care, partial thickness burns are less critical compared to life-threatening hemorrhage.
D. A client who has a punctured femoral artery: This is an emergent situation because it involves severe hemorrhage. The femoral artery is a major artery, and puncture could lead to life-threatening blood loss and requires immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Rub the skin completely dry following a decontamination shower: This is incorrect. The skin should be patted dry, not rubbed, to avoid further irritation.
B. Prepare to administer amyl nitrate: This is incorrect. Amyl nitrate is used for cyanide poisoning, not sarin gas exposure.
C. Provide respiratory support with a plastic airway: While respiratory support may be needed, the priority in sarin gas exposure involves addressing symptoms and potential seizures.
D. Initiate seizure precautions: Sarin gas is a nerve agent that can cause seizures due to its effect on the nervous system. Seizure precautions are necessary for clients exposed to sarin gas.
Correct Answer is D
Explanation
A. Instruct the client to abstain from sexual intercourse for 24 hours prior to the test: While abstaining from sexual intercourse can be recommended to avoid contamination, it is not the most immediate concern before performing the test.
B. Educate the client about the risk factors associated with cervical cancer: While important, this is not a pre-procedural intervention but rather part of general patient education.
C. Assess the client's vital signs, including blood pressure and pulse rate: Vital signs are important but not specifically required before performing a Pap test.
D. Explain the steps of the Pap test procedure to the client: This is the most appropriate intervention as it prepares the client for the procedure, reducing anxiety and ensuring informed consent.
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