A nurse is triaging clients following a mass casualty accident. Which of the following clients should be the nurse's priority?
A client who has an open fractured femur and reports severe pain
A client who has vomited twice and has contusions to both arms and shoulders
A client who has a metal bar protruding from the upper abdomen and is hyperventilating
A client who has several large lacerations to the upper extremities and can explain what occurred
The Correct Answer is C
A) A client who has an open fractured femur and reports severe pain:
An open fractured femur is a serious injury that requires attention due to the risk of infection and bleeding. However, it is not as immediately life-threatening as the complications associated with a protruding metal bar and hyperventilation. The severe pain, while significant, is secondary to addressing the most life-threatening conditions.
B) A client who has vomited twice and has contusions to both arms and shoulders:
While this client may be experiencing symptoms of potential internal injuries or trauma, vomiting and contusions alone do not indicate an immediate life-threatening situation compared to the other conditions. Further assessment is needed, but this client is not the priority in a mass casualty situation.
C) A client who has a metal bar protruding from the upper abdomen and is hyperventilating:
A metal bar protruding from the upper abdomen poses an immediate threat to vital organs, such as the liver, spleen, or intestines, and can cause severe internal bleeding or damage. Hyperventilation indicates possible hypoxia or shock. This client is the highest priority as they face the greatest immediate risk of life-threatening injury.
D) A client who has several large lacerations to the upper extremities and can explain what occurred:
Large lacerations need attention to prevent infection and control bleeding. However, the ability to explain the situation and the absence of immediate life-threatening signs suggest that this client’s condition is less critical compared to others with more severe or life-threatening injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Determine the client's blood type:
Determining the client's blood type is important for blood transfusions or compatibility tests but is not immediately relevant to managing petechiae, which is indicative of a bleeding disorder. The primary concern is addressing the bleeding risk rather than identifying blood type.
B) Implement airborne precautions:
Airborne precautions are used to prevent the spread of airborne pathogens, such as tuberculosis. Petechiae, which are small blood spots on the skin, are not related to airborne infections but rather to bleeding or clotting issues. Therefore, airborne precautions are not appropriate in this situation.
C) Avoid administering IV pain medication:
Avoiding IV pain medication is not necessary unless there is a specific concern about bleeding at the injection site. Petechiae indicate a bleeding problem, but avoiding IV pain medication is not the primary response to this issue. The focus should be on managing the bleeding risk.
D) Institute bleeding precautions:
Petechiae are often a sign of bleeding disorders or platelet deficiencies, common in chronic lymphocytic leukemia. Implementing bleeding precautions is essential to prevent further bleeding complications, such as from minor trauma or invasive procedures. This includes measures like using soft-bristle toothbrushes, avoiding blood draws or injections if possible, and monitoring for signs of bleeding.
Correct Answer is A
Explanation
A) The client advances the weaker leg forward to the cane:
Advancing the weaker leg forward to the cane demonstrates the correct use of the quad cane. This technique helps to provide support and stability, allowing the client to maintain balance while transferring weight onto the cane and weaker leg.
B) The client holds the cane with their left hand:
Holding the cane with the left hand is incorrect for a client with left-sided weakness. The cane should be held in the hand opposite the weaker side, which would be the right hand in this case, to ensure optimal balance and support.
C) The client takes a step with their right foot first:
Taking a step with the right foot first does not indicate proper use of the cane. The correct sequence involves moving the cane and the weaker leg forward together, followed by the stronger leg to maintain stability and support.
D) The client moves the cane 2 feet ahead:
Moving the cane 2 feet ahead is too far and can compromise the client’s balance. The cane should be moved a short distance, typically about 6 to 12 inches, to provide steady support and prevent falls.
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