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 a fracture of the humerus with a 2+ radial pulse in the affected arm
A client who has full-thickness burn injuries over 30% of his total body surface area
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
The nurse should choose a client who is exhibiting agonal respirations with fixed and dilated pupils for transport to the emergency department first. Agonal respirations are a sign of impending respiratory arrest and fixed and dilated pupils indicate that the client's brainstem is herniating, which is a life-threatening condition. Therefore, this client has the highest priority for emergency treatment. The other clients in the question can wait for treatment, although they also require medical attention.
A client who has a fracture of the humerus with a 2+ radial pulse in the affected arm is stable and does not require immediate emergency treatment. The client can wait for treatment and receive pain medication and immobilization of the affected arm until the client is transported to the hospital. A client who has full thickness burn injuries over 30% of his total body surface area also requires medical attention, but this client's condition is not immediately life-threatening. The client needs to be assessed for airway patency, breathing, and circulation and then receive fluid resuscitation and pain management. Finally, an ambulatory client who has a nosebleed and reports feeling dizzy can be assessed and treated in the triage area, as the client's condition is not life-threatening.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When caring for a client with terminal cancer who expresses a desire to discontinue enteral tube feedings, the nurse's priority is to ensure that the client's wishes are respected and appropriate steps are taken. The most suitable action is:
c) Explain the process for completing a living will.
A living will is a legal document that outlines a person's preferences regarding medical treatment in the event they are unable to communicate their wishes. In this situation, the client can express their desire to forgo enteral tube feedings through a living will, ensuring that their wishes are documented and legally recognized.
The other options may not be as appropriate:
a) Request the facility chaplain to visit the client:While spiritual and emotional support is important, the immediate concern is ensuring the client's autonomy in decision-making regarding medical interventions.
b) Ask the client to sign an informed consent form:Informed consent typically pertains to specific medical procedures, and discontinuing enteral tube feedings is more aligned with the broader context of advance care planning.
d) Complete an against medical advice form:This form is typically used when a patient refuses a recommended treatment against the medical team's advice. However, in this case, the client is expressing their own treatment preferences, and the focus should be on facilitating advance care planning and documentation.
Correct Answer is A
Explanation
Explanation: According to the Centers for Disease Control and Prevention, the leading cause of death for adolescents aged 15 to 19 years is motor vehicle crashes. Therefore, it is crucial for the school nurse to give priority to motor vehicle safety when planning safety education for adolescents. The nurse can teach safe driving practices, such as wearing seat belts, avoiding distracted driving, and following traffic laws. The nurse can also encourage parents to set limits and supervise their adolescents' driving, such as restricting night driving and the number of passengers. Although sports injury prevention, gun safety, and substance abuse prevention are essential topics, they are not the leading cause of death for this age group.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.