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A nurse is the triage officer in the emergency department during a disaster when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?

An unconscious adult client who has no respirations, capillary refill is > 2 seconds, and paramedics have already tried to reposition airway without results

A conscious adult client who has a broken tibia, blood pressure of 160/90 mm Hg, and heart rate of 118 beats per minute

An unconscious adult client who has a sucking chest wound, SpO2 of 85%, and capillary refill of < 2 seconds

A conscious adult client who reports shortness of breath, has a respiratory rate of 24/min, and capillary refill of <2 seconds

Answer and Explanation

The Correct Answer is C

C. The unconscious adult client with a sucking chest wound and low SpO2 (85%) is in immediate need of intervention. A sucking chest wound is a life-threatening injury that can lead to respiratory distress and compromised oxygenation. This client requires immediate attention to address the chest wound and improve oxygenation.
A. The unconscious client with no respirations and an ineffective airway attempt is likely beyond rescue, making them lower priority compared to those with potentially reversible conditions.
B. The conscious client with a broken tibia and elevated vital signs is stable enough to be seen after more critical cases are addressed.
D. The conscious client with shortness of breath and a high respiratory rate is concerning but not as immediately life-threatening as a client with a sucking chest wound.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Clay-colored stools are indicative of a bile duct obstruction because bile is not reaching the intestines, leading to pale or clay-colored stools.
B. Tenderness in the left upper abdomen is more commonly associated with issues such as splenic or gastric problems rather than a bile duct obstruction.
C. Ecchymosis of the extremities is not typically associated with bile duct obstruction. It might indicate other issues such as bleeding disorders.
D. Straw-colored urine is not indicative of bile duct obstruction; typically, the urine would appear darker due to elevated bilirubin levels from bile duct obstruction.

A. Place the client on protective isolation. B. Initiate measures to prevent venous thromboembolism. C. Initiate droplet precautions. D. Check the client's most recent platelet level.

Correct Answer is D

Explanation

A. Protective isolation is not directly related to the symptoms of ecchymoses and petechiae but is more relevant for preventing infections in immunocompromised clients.
B. Measures to prevent venous thromboembolism are not the immediate concern given the bleeding symptoms; instead, managing platelet levels and bleeding risks is more critical.
C. Droplet precautions are not indicated based on the described symptoms, which are more related to bleeding disorders rather than infectious conditions requiring droplet precautions.
D. Checking the client's most recent platelet level is the most appropriate action because ecchymoses and petechiae are signs of potential thrombocytopenia (low platelet count), which is common in leukemia. Monitoring platelet levels will help determine if there is a need for interventions to address bleeding risks.

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A nurse is the triage officer in the emergency department during a disaster when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which finding should the nurse expect?

Correct Answer is A

Explanation

A nurse is caring for a client who has been diagnosed with leukemia. The nurse's most recent assessment reveals the presence of ecchymoses on the client's sacral area and petechiae on the forearms. Based on the most recent assessment findings, the nurse should perform which action?

Correct Answer is D

Explanation

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