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 C

Explanation

The correct answer is Choice C.

Choice A rationale:

While maintaining a distance of 3 feet can reduce the risk of direct contact transmission, it is not the most effective measure for contact isolation precautions.
Contact isolation aims to prevent the spread of pathogens that can be transmitted through direct or indirect contact with the infected person or contaminated objects.
A distance of 3 feet may not be sufficient to prevent transmission via droplets or fomites (inanimate objects that can harbor infectious agents).

Choice B rationale:

Sterile gloves are not routinely required for contact isolation precautions.
They are primarily used for sterile procedures or when there is a risk of exposure to blood or body fluids.
For contact isolation, standard clean gloves are usually sufficient to protect against transmission via direct contact.

Choice C rationale:

Leaving equipment that is used routinely in the client's room is a crucial part of contact isolation precautions.
This practice prevents the spread of infection by minimizing the movement of potentially contaminated items outside of the isolation room.
Equipment like stethoscopes, blood pressure cuffs, and thermometers should be dedicated to the client's use and not shared with other patients.

Choice D rationale:

Negative-pressure airflow rooms are used for airborne isolation precautions, which are designed to prevent the spread of pathogens that can be transmitted through the air.
Contact isolation does not specifically require a negative-pressure room, as the primary mode of transmission is through direct or indirect contact, not airborne particles.

A. Decreased blood pressure B. Pale yellow urine C. Periorbital edema D. Increased urination

Correct Answer is C

Explanation

c. Periorbital edema.

Explanation: Acute glomerulonephritis is an inﬂammatory condition aﬀecting the glomeruli of the kidneys. It is commonly characterized by periorbital edema, which is swelling around the eyes. This occurs due to ﬂuid retention and impaired kidney function. Other common manifestations of acute glomerulonephritis include hypertension (increased blood pressure), dark or tea-colored urine (hematuria), decreased urine output, and signs of ﬂuid overload such as edema in the hands, feet, and face.

Option a, decreased blood pressure, is not typically seen in acute glomerulonephritis. Instead, hypertension is a common finding due to ﬂuid retention and increased blood volume.

Option b, pale yellow urine, is not expected in acute glomerulonephritis. Instead, urine may appear dark or

tea-colored due to the presence of blood (hematuria).

Option d, increased urination, is not a characteristic finding in acute glomerulonephritis. Instead, there is often a decrease in urine output or oliguria.

It is important to note that individual presentations may vary, and the nurse should consider the complete clinical picture and the child's specific symptoms when assessing for acute glomerulonephritis.

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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 has been placed on contact isolation precautions. Which of the following interventions should the nurse implement?

Correct Answer is C

Explanation

A nurse is collecting data from a child who has acute glomerulonephritis. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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