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
The first priority in discharge planning for this client should be to arrange for a home health nurse to visit the client following discharge to monitor the client's health and provide support. The client's condition is complex and requires ongoing monitoring and support to prevent relapse and ensure safety.
Providing the client with information on self-help groups and determining home safety measures are also important components of the discharge plan, but they should come after ensuring that the client has the necessary support in place. Contacting a social worker to assist with managing finances is not a priority at this time.
Correct Answer is A
Explanation
Clostridium difficile is a highly contagious bacterium that can survive on surfaces for long periods of time. Cleaning the bathroom with a diluted bleach solution is an effective way to kill the bacteria and prevent its spread. The nurse should also instruct the client to wash their hands frequently with soap and water, as alcohol-based hand sanitizers are not effective against Clostridium difficile.
It is not necessary for the client to wear a surgical mask when away from home, as the bacteria is primarily spread through contact with contaminated surfaces. The use of probiotics may be beneficial in restoring the balance of gut bacteria in some cases, but there is limited evidence to support its use in preventing or treating Clostridium difficile infections.
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