A nurse is planning care for a group of clients. Which of the following clients should the nurse see first?

A client who has a spinal cord injury.

A client who is unconscious.

A client who has peripheral vascular disease.

A client who has a new ankle sprain.

None

Answer and Explanation

The Correct Answer is B

Answer: B. A client who is unconscious.

A. A client who has a spinal cord injury.
While a spinal cord injury is serious and requires close monitoring, this condition does not immediately indicate that the client is unstable or at risk for life-threatening complications compared to an unconscious client. However, if there were signs of respiratory compromise or neurogenic shock, this client could be prioritized higher.

B. A client who is unconscious.
An unconscious client should be seen first because their condition may indicate a critical issue such as impaired airway, breathing, or circulation (ABC). Immediate assessment is needed to ensure the airway is clear, breathing is adequate, and circulation is stable, as these are life-threatening concerns.

C. A client who has peripheral vascular disease.
Clients with peripheral vascular disease (PVD) typically have chronic issues related to circulation in the limbs, which can cause pain and discomfort but are not usually immediately life-threatening. While important, this client is not the top priority compared to an unconscious client.

D. A client who has a new ankle sprain.
A new ankle sprain is painful and requires treatment, but it is not life-threatening. The nurse should address this client after ensuring the more urgent needs of other clients are met, such as the unconscious client who may require immediate interventions to preserve life.

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Correct Answer is C

Explanation

Answer: C. Place a surgical mask on the client when they leave their room.

Rationale:

A) Wear a surgical mask when within 0.6 m (2 ft) of the client.
While it is necessary to wear a surgical mask when in close proximity to a client on droplet precautions, the distance specified (0.6 m or 2 ft) is less than the standard recommended distance of 1 meter (3 feet). Therefore, this option is not fully aligned with best practices.

B) Move the client to a positive airflow room.
Positive airflow rooms are typically used for clients with immunosuppression or those who need protection from airborne pathogens, not for those on droplet precautions. This action is not appropriate for a client requiring droplet precautions.

C) Place a surgical mask on the client when they leave their room.
This action is appropriate and essential to minimize the risk of transmission of infectious agents to others when the client is moving outside their isolation area. The client wearing a mask is a key part of droplet precautions.

D) Remove fresh flowers from the client’s room.
While it may be necessary to remove fresh flowers in certain cases (such as for neutropenic clients), this is not specifically related to droplet precautions. Droplet precautions focus primarily on respiratory secretions and do not directly involve the presence of flowers.

A. A client who has haemorrhoids B. A client who had recent oral surgery C. A client who has a coagulation disorder D. A client who is drinking ice water

Correct Answer is A

Explanation

Answer: A

Rationale:

A) A client who has hemorrhoids: An oral temperature is appropriate for this client as there are no contraindications for using the oral route. Hemorrhoids do not affect the accuracy or safety of oral temperature measurement.

B) A client who had recent oral surgery: Oral temperature measurement should be avoided for this client as it may cause discomfort or disrupt the healing process. Alternative routes, such as tympanic or axillary, are more appropriate.

C) A client who has a coagulation disorder: Oral temperature measurement might be risky in clients with coagulation disorders due to the potential for trauma or bleeding from the oral mucosa. A non-invasive method is preferable for safety.

D) A client who is drinking ice water: Drinking ice water can temporarily lower the temperature in the oral cavity, leading to inaccurate readings. The nurse should wait 15–30 minutes before measuring an oral temperature.

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A nurse is planning care for a group of clients. Which of the following clients should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is placed on droplet precautions. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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