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 ["125"]
Explanation
To calculate the infusion rate for an IV, the total volume to be infused (in this case, 1000 mL) is divided by the total time of infusion (8 hours). So, the calculation would be 1000 mL divided by 8 hours, which equals 125 mL per hour.
Correct Answer is ["0.5"]
Explanation
To calculate the correct dose of digoxin, the nurse needs to convert the prescribed micrograms (mcg) to milligrams (mg) as the medication available is measured in mg. One milligram (mg) is equal to 1000 micrograms (mcg). Therefore, 125 mcg is equal to 0.125 mg. Since the available medication is 0.25 mg per tablet, the nurse would administer half a tablet to achieve the 0.125 mg dose.
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