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 B
Explanation
Applying heat to the affected joints can help relieve pain and stiffness. A heating pad or warm compress can be used to apply heat to the hands.
The other options are not correct because:
a) Sleeping on a soft mattress is not mentioned as a way to manage osteoarthritis symptoms.
b) Aspirin should be taken with food or milk to reduce stomach irritation.
c) Exercising inflamed joints excessively can worsen symptoms. It is important to balance rest and activity.
Correct Answer is A
Explanation
The action by the AP that indicates an understanding of the procedure is elevating the client's legs before applying the stockings. Elevating the legs can help reduce swelling and make it easier to apply the stockings.
Option b is incorrect because instructing the client to dorsiflex their feet while applying the stockings may not be necessary.
Option c is incorrect because massaging the client's legs before applying the stockings may not be necessary or appropriate.
Option d is incorrect because folding the top of the stockings over after applying them may not be necessary or appropriate.
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