A nurse is assisting with triaging clients in a mass casualty situation. The nurse should recommend that which of the following clients receive care first?
A client who has a head injury and whose pupils are fixed and dilated
A client who has a dislocated shoulder and reports a pain level of 8 on a scale from 0 to 10
A client who has a 20.3-cm (8-in) scalp laceration with intermittent bleeding
A client who has diminished breath sounds and paradoxical chest movement
The Correct Answer is D
The nurse should recommend that the client who has diminished breath sounds and paradoxical chest movement receive care first. This client is likely experiencing a tension pneumothorax, which is a life-threatening condition that requires immediate intervention.
Option a is incorrect because a client who has a head injury and whose pupils are fixed and dilated may have experienced brain death and may not be able to be resuscitated.
Option b is incorrect because a dislocated shoulder, while painful, is not immediately life-threatening. Option c is incorrect because a scalp laceration with intermittent bleeding can be managed with pressure and is not immediately life-threatening.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A newly licensed nurse who is having difficulty finishing client care tasks during their shift should try to complete one task before moving on to the next. This can help the nurse stay focused and organized, and prevent them from becoming overwhelmed.
The other options are not recommended for time management.
a) Delegating complicated tasks to an RNmay not be appropriate or allowed, depending on the task and the nurse's scope of practice.
b) Documenting all client care at the end of the shiftcan lead to errors and omissions.
c) Performing quick tasks before time-consuming tasks may not be the most efficient use of time, as it can lead to unfinished tasks at the end of the shift.
Correct Answer is C
Explanation
A nurse reviewing the laboratory results of a client who has DKA should identify that the client's ABG results of pH 7.30, PaCO₂ 34 mm Hg and HCO₃ 21 mEq/L indicate metabolic acidosis. Metabolic acidosis is an acid-base imbalance characterized by a low pH (less than 7.35) and a low bicarbonate level (less than 22 mEq/L).
The other options are not correct.
a) Respiratory alkalosisis an acid-base imbalance characterized by a high pH (greater than 7.45) and a low PaCO₂ (less than 35 mm Hg).
b) Metabolic alkalosisis an acid-base imbalance characterized by a high pH (greater than 7.45) and a high bicarbonate level (greater than 26 mEq/L).
d) Respiratory acidosisis an acid-base imbalance characterized by a low pH (less than 7.35) and a high PaCO₂ (greater than 45 mm Hg).
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.