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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Related Questions
Correct Answer is D
Explanation
The presence of alcohol on a nurse's breath raises concerns regarding impairment and the potential for compromised patient safety. It is crucial to prioritize patient safety and prevent any potential harm. Removing the nurse from the client care area ensures that immediate patient safety is addressed and minimizes the risk of any adverse events.
Call the supervisor to ask for another nurse: While involving the supervisor is important, it should not be the first action taken in this situation. The immediate priority is to address patient safety by removing the nurse from the client care area.
Assign clients to the remaining staff: Assigning clients to the remaining staff should not be the first action taken because it may compromise patient safety if the nurse in question is impaired. It is important to ensure that the nurse is removed from the client care area before reassigning the clients to other staff members.
Document objective findings about the situation: Documenting the objective findings about the situation is important for accurate record-keeping and reporting. However, it should not be the first action taken when immediate patient safety is at stake. Removing the nurse from the client care area is the priority.
Correct Answer is D
Explanation
The client's partner assisting them with their meal tray (option d) is not as important as the other information and may not need to be included in the change-of-shift report.
A nurse providing change-of-shift report for a client who has heart failure should include all of the above information in the report.
The client's most recent blood pressure reading,morning laboratory results, and presence of pitting edema in the lower extremities are all important pieces of information that the incoming nurse should be aware of.
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