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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Grapes are a common choking hazard for young children, especially toddlers, due to their small size, round shape, and slippery texture. The size and shape of grapes can block the airway and pose a significant risk if not properly cut or prepared before being given to a toddler. It is recommended to cut grapes into small pieces or slice them lengthwise to reduce the risk of choking.
While potatoes, corn, and oranges can also pose a choking risk if not properly prepared or cut into age-appropriate sizes, they are not as commonly associated with choking incidents in toddlers as grapes are. Nonetheless, it is essential for parents and caregivers to be aware of appropriate food preparation techniques and supervise children during meals to ensure their safety.
Correct Answer is B
Explanation
The most concerning finding in the assessment of a client's right leg after a femoropopliteal bypass graft would be if the client's pedal pulse in the right foot is not palpable. This could indicate a problem with blood flow to the limb.
The other options are also concerning and should be reported to the healthcare provider.
a) A cooler footmay indicate decreased blood flow to the limb.
c) A capillary refill time of 5 secondsmay also indicate decreased blood flow.
d) A pain level of 8 on a scale from 0 to 10should also be reported and addressed.
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