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 B

Explanation

b. Give directions using simple phrases.

The correct answer is b. Give directions using simple phrases.

Explanation:

When assisting with the plan of care for a client with Alzheimer's disease, it is important to consider their cognitive impairments and provide appropriate interventions. Giving directions using simple phrases is recommended because it helps the client beter understand and follow instructions. Complex or lengthy directions can be confusing and overwhelming for individuals with Alzheimer's disease. Using clear and concise language can enhance communication and facilitate the client's ability to engage in activities of daily living.

Explanation for the other options:

a. Encourage the client to talk about current events: While social interaction and engagement are beneficial for clients with Alzheimer's disease, their ability to comprehend and discuss current events may be limited due to cognitive impairments. It is important to adapt communication to the client's cognitive abilities and interests.

c. Orient the client to time and place twice per day: Frequent orientation to time and place can be helpful for clients with Alzheimer's disease, but the specific frequency should be based on the individual's needs and preferences. Some individuals may require more frequent orientation, while others may find it overwhelming. The plan of care should be individualized to address the client's specific needs.

d. Rotate assistive personnel to help the client with ADLs: Consistency and familiarity are important for individuals with Alzheimer's disease. Rotating assistive personnel frequently may disrupt the client's routine and cause increased confusion and agitation. Whenever possible, it is best to maintain a consistent caregiving team to provide familiarity and establish a therapeutic relationship with the client.

In summary, giving directions using simple phrases is an appropriate action when assisting with the plan of care for a client with Alzheimer's disease. This approach promotes eﬀective communication and enhances the client's ability to understand and follow instructions.

A. Raise the head of the client's bed to 30 degrees. B. Cleanse the client's body while wearing sterile gloves. C. Remove the client's dentures and close their mouth D. Apply surgical tape to the client's eyes

Correct Answer is A

Explanation

After a patient dies, postmortem care includes preparing them for family viewing . The nurse should place the body in the supine position, with the arms at the sides and the head on a pillow. Then elevate the head of the bed 30 degrees to prevent discoloration from blood setling in the face.

The other options are not correct because:

b) The nurse should cleanse the client's body while wearing appropriate personal protective equipment (PPE) based on indications for isolation precautions, not necessarily sterile gloves.

c) If the patient wore dentures and your facility’s policy permits, gently insert them; then close the mouth.

d) The nurse should close the eyes by gently pressing on the lids with their fingertips. If they don’t stay closed, place moist coton balls on the eyelids for a few minutes, and then try again to close them. Surgical tape is not mentioned as necessary .

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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 assisting with the plan of care for a client who has Alzheimer's disease. Which of the following actions should the nurse recommend for the plan of care?

Correct Answer is B

Explanation

A nurse is providing postmortem care for a client prior to the family viewing the body. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse and assistive personnel (AP) are caring for a client who requests a PRN pain medication. After the nurse administers the medication, which of the following tasks should the nurse assign to the AP?

A nurse in a clinic is reinforcing teaching with a client who has a new prescription for a combination contraceptive transdermal patch. Which of the following should the nurse include in the teaching?

A nurse in the newborn nursery is collecting data about a newborn's Moro reﬂex. Which of the following actions should the nurse take to elicit this reﬂex?

A nurse is reviewing the laboratory results of a client who has DKA. The client's ABG results are pH 7.30, PaCO₂ 34 mm Hg and HCO₃ 21 mEq/L. The nurse should identify that these values indicate which of the following acid-base imbalances?

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A nurse is planning to obtain blood from a newborn via a heel stick. Which of the following actions should the nurse take?

A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?