A nurse is triaging a group of clients following a disaster. Which of the following clients should the nurse recommend for treatment first?

A client who has bipolar disorder and is exhibiting signs of hallucination

A client who has major burns over 75% of their body surface area

A client who has two open chest wounds with a left tracheal deviation

A client who has a neck injury and is unable to breathe spontaneously

Answer and Explanation

The Correct Answer is D

Choice A reason: A client who has bipolar disorder and is exhibiting signs of hallucination is not the highest priority for treatment. The client may have a psychiatric emergency, but their condition is not life-threatening or unstable. The nurse should assess the client's safety and provide emotional support, but they can wait for further intervention.

Choice B reason: A client who has major burns over 75% of their body surface area is a high priority for treatment, but not the highest. The client has a serious injury that can cause shock, infection, and organ failure. The nurse should monitor the client's vital signs, fluid status, and wound care, but they can wait for a short time.

Choice C reason: A client who has two open chest wounds with a left tracheal deviation is a high priority for treatment, but not the highest. The client has a tension pneumothorax, which is a life-threatening condition that causes air to accumulate in the pleural space and compress the lung and the heart. The nurse should seal the wounds with an occlusive dressing and prepare for chest tube insertion, but they can wait for a few minutes.

Choice D reason: A client who has a neck injury and is unable to breathe spontaneously is the highest priority for treatment. The client has a respiratory emergency, which is the most urgent condition that requires immediate intervention. The nurse should establish an airway, provide oxygen, and stabilize the neck, as well as call for help and notify the provider.

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Correct Answer is C

Explanation

Choice A reason: Demonstrating use of the pump during medication administration is not the priority action by the charge nurse. This would not ensure that all staff nurses are competent and confident in using the new pump. It would also interrupt the workflow and patient care.

Choice B reason: Pairing an inexperienced nurse with an experienced nurse is not the priority action by the charge nurse. This would not address the knowledge gap of the staff nurses who are not paired. It would also create a dependency on the experienced nurse and a potential risk for errors.

Choice C reason: Planning an in-service education program on the unit is the priority action by the charge nurse. This would provide the staff nurses with the opportunity to learn about the new pump, its features, functions, and troubleshooting. It would also allow the charge nurse to assess the staff nurses' learning needs and evaluate their competency.

Choice D reason: Contacting the manufacturer of the pump for assistance is not the priority action by the charge nurse. This would not address the immediate needs of the staff nurses who are using the new pump. It would also depend on the availability and responsiveness of the manufacturer.

A. The client's vital signs B. The client's name C. The client's code status D. A prescribed consultation

Correct Answer is B

Explanation

Choice A reason: The client's vital signs are not part of the background information, but rather the assessment information. The background information should include relevant and concise data about the client's history, diagnosis, and treatment.

Choice B reason: The client's name is part of the background information, as it identifies the client and establishes rapport. The name should be the first thing the nurse says when initiating the SBAR communication.

Choice C reason: The client's code status is not part of the background information, but rather the recommendation information. The code status should be communicated at the end of the SBAR communication, along with any other suggestions or requests for the receiving nurse.

Choice D reason: A prescribed consultation is not part of the background information, but rather the situation information. The situation information should describe the current problem or reason for the transfer.

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A nurse is triaging a group of clients following a disaster. Which of the following clients should the nurse recommend for treatment first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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