A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?
A conscious adult client who reports shortness of breath, has a respiratory rate of 24/min, and capillary refill of <2 seconds
A conscious adult client who has a dislocated right shoulder, respiratory rate of 18/min, and capillary refill of <2 seconds
An unconscious adult client who has a sucking chest wound, respirations of 38/min, and capillary refill of <2 seconds
An unconscious adult client who has no respirations, capillary refill is 2 seconds and paramedics have already tried to reposition airway without results
The Correct Answer is C
A. This client has respiratory distress but is conscious and stable, requiring urgent but not immediate attention compared to other critical conditions.
B. This client has a dislocated shoulder, which is painful and needs attention but is not life-threatening compared to other conditions.
C. This client is unconscious with a sucking chest wound and high respiratory rate, indicating severe respiratory compromise and needing immediate intervention to prevent further deterioration.
D. This client is also unconscious with no respirations despite attempted airway management, indicating a need for immediate resuscitative efforts, potentially including CPR.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Full body alopecia is a common side effect of chemotherapy but not directly related to myelosuppression.
B. Diarrhea and dehydration can occur with certain chemotherapeutic agents but are not specific to myelosuppression.
C. Anorexia and malnutrition are common during chemotherapy but are not specific to myelosuppression.
D. Myelosuppression can lead to decreased platelets and clotting factors, increasing the risk of bleeding from the gums and other sites.
Correct Answer is C
Explanation
A. Applying a warm pack can increase the absorption of venom and worsen symptoms.
B. Applying a tourniquet can restrict blood flow and worsen local effects of the venom.
C. Removing the stinger by scraping it off with a knife blade is the correct method to prevent further venom injection.
D. Sucking the wound can introduce infection and is not recommended.
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