A nurse is assisting with triaging clients after a mass casualty event. Which of the following clients should the nurse attend to first?
A client who has a splinted open fracture of the left medial malleolus.
A client who has a penetrating head injury and is experiencing seizures.
A client who has severe respiratory stridor and a deviated trachea.
A client who has a small circular partial-thickness burn of the left calf.
The Correct Answer is C
Choice A reason: An open fracture, while needing medical attention, is not immediately life-threatening. The client's condition is stable enough to wait while more critical cases are attended to.
Choice B reason: A penetrating head injury with seizures is a critical condition. However, ensuring a patent airway takes precedence in emergency situations. This client's seizures indicate serious brain injury, but the immediate threat to life, such as airway obstruction, must be prioritized.
Choice C reason: Severe respiratory stridor and a deviated trachea indicate a life-threatening airway obstruction. This client needs immediate attention to secure the airway and prevent respiratory failure. This is the highest priority because without a clear airway, the client will not survive long enough to benefit from other interventions.
Choice D reason: A partial-thickness burn, although painful and requiring treatment, is not immediately life-threatening. This client can safely wait while those with more critical needs are attended to.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: The correct answer is a because orange juice is high in potassium and should be avoided by clients with chronic kidney disease to prevent hyperkalemia, which can lead to serious cardiac complications.
Choice B reason: The correct answer is b because watermelon, although refreshing, is high in potassium and should be limited or avoided by clients with chronic kidney disease to maintain safe potassium levels.
Choice C reason: The correct answer is c because bananas are well-known for their high potassium content and should be avoided by clients with chronic kidney disease to prevent elevated potassium levels in the blood.
Choice D reason: Corn flakes cereal is generally low in potassium and is not a food that needs to be avoided in clients with chronic kidney disease. It can be included in their diet in moderation.
Choice E reason: White rice is also low in potassium and can be safely consumed by clients with chronic kidney disease. It does not pose a significant risk of increasing potassium levels.
Correct Answer is B
Explanation
Choice A reason: Taking a laxative the day before an IVP is a common preparation to clear the intestines for better imaging. This statement does not require additional data collection.
Choice B reason: The correct answer is b because taking metformin before an IVP can increase the risk of lactic acidosis, a serious complication. Metformin should be temporarily discontinued before and after the procedure, and the nurse should gather more information to manage the client’s diabetes safely.
Choice C reason: Fasting before an IVP is standard procedure to ensure clear imaging. This statement does not require additional data collection.
Choice D reason: Painful voiding may be related to kidney stones but is not a contraindication for an IVP. This statement does not require additional data collection.
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