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

Answer and Explanation

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.

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Correct Answer is A

Explanation

The nurse should administer scheduled pain medications to a client who is near death. This is an important nursing intervention to ensure that the client is comfortable and free from pain.

b) Providing oral care every 6 hours is important, but it may not be the highest priority for a client who is near death.

c) Administering liquids using a syringe may not be necessary or appropriate for a client who is near death.

d) Whispering when talking to family members is not necessary. The nurse should communicate openly and honestly with the family members.

A. Hypernatremia B. Hypercalcemia C. Hypermagnesemia D. Hyperkalemia

Correct Answer is D

Explanation

The nurse should expect to find hyperkalemia in the medical record of a client who has sustained a full- thickness burn and is in the emergent phase of the burn. This is due to the release of potassium from damaged cells into the bloodstream.

a) Hypernatremia is not a common finding in the emergent phase of a burn.

b) Hypercalcemia is not a common finding in the emergent phase of a burn.

c) Hypermagnesemia is not a common finding in the emergent phase of a burn.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is near death. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is reviewing the medical record of a client who has sustained a full-thickness burn and is in the emergent phase of the burn. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is reinforcing discharge teaching with the guardian of a client who is neutropenic. Which of the following instructions should the nurse include?

A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following laboratory results indicates a possible complication of this therapy?

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A charge nurse in a long-term care facility notices the smell of alcohol on a nurse's breath. Which of the following actions should the nurse take first?

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