A nurse is assisting with triaging clients following an explosion. Which of the following clients should the nurse identify as the highest priority?

A conscious adult client who has second-degree burns on both lower legs; respiratory rate is > 30/min

A conscious adult client wearing a medic-alert diabetic bracelet, client reports feeling clammy and shaky.

An unconscious adult client who has a large head wound with gray matter exposed; absent respirations

An unconscious 6-month-old infant with no respirations, no visible injuries

Answer and Explanation

The Correct Answer is C

A. This client has significant burns but is conscious and breathing, indicating adequate airway and respiratory effort.
B. This client is conscious but has symptoms potentially related to hypoglycemia rather than life-threatening injuries.
C. This client is unconscious with a severe head injury and absent respirations, indicating a compromised airway and immediate life-threatening condition.
D. This infant is unconscious with no respirations, requiring immediate attention but is not as urgent as the client with the severe head injury and compromised airway.

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Correct Answer is D

Explanation

A. Removing the elastic bandages could lead to rapid systemic absorption of venom, increasing the severity of envenomation.
B. Pain management is important but secondary to administering anti-venom in cases of snakebite.
C. Discharging the client without proper evaluation and treatment for potential envenomation could lead to serious complications.
D. Administering the appropriate anti-venom is critical to neutralize venom effects and prevent worsening of symptoms.

A. Give acetaminophen (Tylenol) rectal suppository. B. Provide O2 at 2 L/min with a nasal cannula. C. Apply wet sheets and a fan to the patient D. Start lactated Ringer's solution at 1000 mL/hr

Correct Answer is C

Explanation

A. Giving acetaminophen is appropriate for fever reduction but does not address the hypotension and potential dehydration in this scenario.
B. Providing oxygen is important, but the patient's hypotension requires fluid resuscitation as the initial priority.
C. Applying wet sheets and a fan are immediate actions focused on rapid cooling. The priority is to lower the body temperature as quickly as possible to prevent organ damage.
D. Starting lactated Ringer's solution at a high rate is crucial to address hypovolemia and to cool the patient effectively through intravenous hydration but should be done after cooling the patient using a wet sheet.

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A nurse is assisting with triaging clients following an explosion. Which of the following clients should the nurse identify as the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is assessing a client who was bitten on the left leg by a poisonous snake. The client has placed elastic bandages snuggly above and below the bite marks and is in no apparent distress. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

An unresponsive 79-yr-old patient is admitted to the emergency department (ED) during a summer heat wave. The patient's core temperature is 105.4" F (40.8" C), blood pressure (BP) is 88/50 mm Hg, and pulse is 112 beats/min. What action should the nurse plan to take?

Correct Answer is C

Explanation

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