Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Inserting a new indwelling urinary catheter could introduce new pathogens and increase the risk of infection rather than reduce it. Indwelling catheters are a known risk factor for urinary tract infections and should be avoided if possible.
B. Collecting blood cultures is an important diagnostic step, especially if sepsis is suspected. However, this action alone does not directly reduce the risk of septic shock. It is a part of the process but not the most immediate intervention.
C. Initiating intravenous (IV) antibiotics is the most critical intervention to reduce the risk of septic shock. Prompt administration of antibiotics can help control the infection before it progresses to sepsis, making this the priority action.
D. Obtaining placement of an intravenous access for fluid administration is necessary for managing sepsis or septic shock, but the first step should be administering antibiotics to treat the infection causing the sepsis. Fluid administration supports blood pressure and circulation but does not directly address the underlying infection.

A. Darken the client's room and close the door. B. Increase fluid intake. C. Administer naproxen sodium. D. Elevate the head of the bed to 30°.

Correct Answer is B

Explanation

A. Darkening the room can help reduce light sensitivity, but it does not address the underlying cause of the headache.
B. Increasing fluid intake is effective in managing a headache after a lumbar puncture because it helps replenish cerebrospinal fluid (CSF) and reduces the risk of post-lumbar puncture headache, which often results from CSF leakage.
C. Naproxen sodium can provide relief for headache pain, but increasing fluid intake addresses the root cause of the headache more directly.
D. Elevating the head of the bed is generally recommended for certain conditions, but it is not the most effective strategy for addressing a post-lumbar puncture headache, which is better managed by increasing fluid intake.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An immunocompromised older adult has developed a urinary tract infection, and the healthcare team recognizes the need to prevent an exacerbation of the client's infection that could result in sepsis and septic shock. What action should the nurse perform to reduce the client's risk of septic shock?

Correct Answer is C

Explanation

A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?

Correct Answer is B

Explanation

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection?

A nurse is providing dietary teaching for a client who has Cushing disease. Which of the following recommendations should the nurse include in the teaching?

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

A nurse is caring for a client in septic shock. The client is still hypotensive and lethargic following a 2,500 mL fluid bolus of lactated Ringer (LR) solution. Which of the following interventions does the nurse anticipate next?

A nurse is assessing a client with chronic liver failure who tells the nurse he is experiencing spontaneous episodes of bleeding and has noted increased areas of bruising on his arms. The nurse suspects the client has a deficiency in which of the following vitamins?

A nurse is caring for a client in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values?

A nurse is caring for a client who is experiencing pooling of blood in the periphery. Which of the following occurs in a client with distributive shock?