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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

Answer and Explanation

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.

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Correct Answer is ["A","B","E","F"]

Explanation

A. Tenderness in the area of the transplant incision can be a sign of inflammation or rejection.
B. Bilateral edema (swelling) in the lower legs can be a sign of fluid retention, which can occur with kidney dysfunction or rejection.
C. While high blood pressure can be a concern, it's not a specific indicator of transplant rejection in this scenario.
D. The sodium level is within normal limits in this case, decreasing the risk of a transplant rejection.
E. An elevated creatinine level can indicate worsening kidney function, which could be a sign of rejection.
F. Hypoactive bowel sounds in all four quadrants can suggest decreased blood flow or intestinal ischemia, which can be a complication of transplant rejection.
G. Normal lung sounds are not necessarily indicative of rejection.

A. Women should have a yearly clinical breast examination starting at age 45. B. Clients should have a colonoscopy at age 40 and every 10 years thereafter. C. Women should start yearly mammograms at age 30. D. Clients should have a yearly test for fecal occult blood.

Correct Answer is D

Explanation

A. Clinical breast examinations are generally recommended every 1 to 3 years for women in their 20s and 30s and annually for women 40 and older. However, the emphasis has shifted towards mammography as a primary screening tool.

B. Routine screening for colorectal cancer typically begins at age 45 for average-risk individuals, not 40. Colonoscopies are generally recommended every 10 years if results are normal.

C. Mammograms are typically recommended to start at age 40 for average-risk women, with yearly screening starting at age 45 or 50 depending on guidelines.

D. Annual testing for fecal occult blood is a recommended screening method for colorectal cancer starting at age 45, as it helps detect blood in the stool which can be an early sign of colorectal cancer.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is admitted to the emergency department for fatigue. Exhibits Which of the following findings indicate that the client may be experiencing transplant rejection? (Select all that apply).

Correct Answer is ["A","B","E","F"]

Explanation

A nurse is teaching a class at a community center to a group of young adult, adult, and older adult clients regarding regular screening recommendations for cancer prevention. Which of the following information should the nurse include?

Correct Answer is D

Explanation

During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next?

When requested to plan the response to the potential use of smallpox as a biological weapon, what should the emergency department (ED) nurse manager expect to obtain?

A nurse is caring for a client who has a new diagnosis of lung cancer. Exhibits For each potential provider's prescription at 4 weeks, click to specify if the prescription is anticipated, nonessential, or contraindicated for the client.

A nurse is caring for a client who has cancer and is undergoing chemotherapy. Exhibits Which of the following assessments indicates an improvement in the client's condition? (Select all that apply.)

The nurse teaches patients about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions?

A nurse is caring for a client who has had an open radical prostatectomy. Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

The charge nurse is assigning semiprivate rooms for new admissions. Which patient could safely be assigned as a roommate for a patient who has acute rejection of an organ transplant?