A nurse is triaging clients who were involved in a commuter train crash. Which of the following clients should the nurse choose for transport to the emergency department first?
A client who has full thickness burn injuries over 30% of his total body surface area.
A client who has a fracture of the humerus with a 2nd radial pulse in the affected arm.
A client who is exhibiting agonal respirations with fixed and dilated pupils.
An ambulatory client who has a nosebleed and reports feeling dizzy.
The Correct Answer is C
In a triage situation, the nurse should prioritize clients based on the severity of their condition and the potential for their condition to deteriorate rapidly. A client who is exhibiting agonal respirations with fixed and dilated pupils is likely experiencing a life-threatening emergency, such as respiratory or cardiac arrest, and should be transported to the emergency department first.
The nurse should initiate immediate resuscitation efforts and notify the emergency department of the client's condition.
The client with full- thickness burn injuries over 30% of his total body surface area should be transported next, as this is also a life-threatening emergency.
The client with a fracture of the humerus with a 2nd radial pulse in the affected arm can wait a bit longer as he has a palpable radial pulse indicating circulation is maintained.
The ambulatory client with a nosebleed and feeling dizzy is the least critical and can be managed in a non- emergency setting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
In a situation where the nurse and the client do not speak the same language, it is important to ensure effective communication. Using a family member or a member of the client's community to interpret may not be appropriate as they may not have the necessary knowledge and skills to provide accurate and complete interpretation.
Professional interpreters are best suited fo
r this task. Before contacting an interpreter, the nurse should identify the client's spoken dialect to ensure that an appropriate interpreter is used. This will help to ensure effective communication between the nurse and the client and promote understanding of the procedure and any education that is provided. Using professional terminology when providing education may not be effective, as it may not be understood by the client.
Correct Answer is B
Explanation
This statement is appropriate because it is a recommended preventive health measure for women in this age group to detect any potential eye problems early on.
Option A is incorrect because the American Diabetes Association recommends that individuals over the age of 45 should have their fasting blood glucose level checked every 3 years, not every 6 years.
Option C is incorrect because the United States Preventive Services Task Force does not recommend routine hearing screening in adults who do not have any symptoms of hearing loss.
Option D is incorrect because the American Cancer Society recommends that individuals over the age of 50 should have a screening colonoscopy every 10 years or a fecal occult blood test every year, not every other year until the age of 74.
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