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 B

Explanation

A. Reviewing the client's medical record is important for understanding their health status but is not directly related to investigating an injury claim at the workplace.
B. Reviewing the workplace procedures and protocols manual is crucial to understanding the standards and practices relevant to the injury claim.
C. The Occupational Safety and Health Act provides guidelines and regulations for workplace safety but does not provide specific details about individual injury claims.
D. The client's attendance record at health and safety seminars may be informative but is less directly relevant to investigating the injury claim compared to reviewing workplace protocols.

A. Avoid crowds. B. Take temperature weekly. C. Perform mild exercise, such as gardening. D. Eat plenty of fresh fruits and vegetables.

Correct Answer is A

Explanation

A. Neutropenic clients have reduced immune function and are at increased risk of infection from exposure to crowds and potential pathogens.
B. Taking temperatures daily, not weekly, is important to monitor for signs of infection in neutropenic clients.
C. Mild exercise is generally encouraged but should be discussed with the healthcare provider to ensure safety and infection prevention.
D. Fresh fruits and vegetables are important for overall nutrition but should be washed thoroughly to reduce the risk of infection.

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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

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Correct Answer is B

Explanation

A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

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