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 D

No explanation

A. Pull the auricle upward and outward. B. Pull the auricle downward and backward. C. Pull the auricle upward and backward. D. Pull the auricle downward and outward.

Correct Answer is A

Explanation

Answer: A. Pull the auricle upward and outward.

Rationale:

A. Pull the auricle upward and outward:
Pulling the auricle upward and outward is the recommended technique for instilling ear drops in an adult. This method straightens the ear canal, allowing better access for the medication to reach the target area. It is essential for effective delivery and absorption of the otic suspension.

B. Pull the auricle downward and backward:
Pulling the auricle downward and backward is appropriate for children under three years old, as it aligns their shorter and straighter ear canal. In adults, this approach would not straighten the canal sufficiently for optimal medication instillation.

C. Pull the auricle upward and backward:
While pulling the auricle upward and backward can straighten the adult ear canal, the optimal direction to ensure the ear canal is fully open is upward and outward. This position allows the medication to reach deeper parts of the ear canal effectively.

D. Pull the auricle downward and outward:
Pulling the auricle downward and outward is not suitable for adults and does not provide the correct alignment for an adult ear canal. This technique is ineffective in reaching the canal's deeper parts in adult clients, thus limiting the efficacy of the medication.

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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

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Correct Answer is A

Explanation

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