A nurse working in an emergency department is performing triage. To which of the following clients should the nurse assign priority?

A client who reports night sweats and fever for the last week

A client who has compound fractures of the tibia and humerus

A client who reports severe vomiting and diarrhea

A client who has soot markings around each naris following a house fire

Answer and Explanation

The Correct Answer is D

a. A client who reports night sweats and fever for the last week:

Night sweats and fever can be indicative of various underlying conditions, including infections. While these symptoms may require medical attention, they do not necessarily indicate an immediately life-threatening condition compared to other options.

b. A client who has compound fractures of the tibia and humerus:

Compound fractures involve broken bones that penetrate through the skin, leading to a risk of severe bleeding, infection, and other complications. This client's injuries are significant and require immediate attention to prevent further complications and provide pain management and stabilization.

c. A client who reports severe vomiting and diarrhea:

Severe vomiting and diarrhea can lead to dehydration, electrolyte imbalances, and other complications, especially if prolonged or accompanied by other symptoms such as fever. While this client requires prompt assessment and treatment, the urgency may not be as high as for other conditions.

d. A client who has soot markings around each naris following a house fire:

Soot markings around the nares (nostrils) suggest inhalation injury, which can lead to airway compromise, respiratory distress, and other serious complications. This client requires immediate assessment and intervention to ensure airway patency, oxygenation, and respiratory support.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

a. Providing a 10-minute rest period prior to meals:

This action is not specifically related to feeding technique for clients with dysphagia. While providing a rest period before meals may be beneficial for some clients, especially those who experience fatigue or dyspnea, it is not a standard technique for managing dysphagia during mealtime.

b. Elevating the head of the client’s bed to 30 degrees during mealtime:

The head of the bed should be elevated to at least 45–90 degrees during meals to minimize the risk of aspiration. A 30-degree elevation is insufficient for safe swallowing and increases the likelihood of aspiration.

c. Instructing the client to place her chin toward her chest when swallowing:

This technique, known as the chin-tuck maneuver, helps reduce the risk of aspiration in clients with dysphagia by improving airway protection and directing food and liquid down the esophagus instead of the trachea. It is a widely recommended method to promote safe swallowing.

d. Withholding fluids until the end of the meal:

Fluids should not be withheld until the end of the meal as they are often necessary to help the client swallow food safely and prevent choking. Thickened fluids may be prescribed for clients with dysphagia to aid in safe swallowing.

A. “I will wear a surgical mask within 3 feet of the client.” B. “I will check that the room has a high-efficiency particulate air filtration system.” C. “I will wear an N95 respirator when providing care for the client.” D. “I will assign the client to a room with positive airflow.”

Correct Answer is A

Explanation

a. "I will wear a surgical mask within 3ft of the client":

This statement is correct. Wearing a surgical mask within 3 feet of the client helps prevent the transmission of respiratory droplets from the client to the healthcare provider or others in close proximity.

b. "I will check that the room has a high-efficiency particulate air filtration system":

This statement is not directly related to implementing droplet precautions. While a high-efficiency particulate air (HEPA) filtration system can help improve air quality in a healthcare setting, it is not a standard requirement for implementing droplet precautions.

c. "I will wear an N95 respirator when providing care for the client":

This statement is not accurate for implementing droplet precautions for influenza. N95 respirators are used for airborne precautions, which are indicated for diseases transmitted by smaller droplet nuclei (e.g., tuberculosis). Surgical masks are typically sufficient for preventing the transmission of respiratory droplets during care for clients with influenza.

d. "I will assign the client to a room with positive airflow":

This statement is not appropriate for implementing droplet precautions. Positive airflow rooms are typically used for clients requiring airborne precautions to prevent the spread of infectious agents in the air. In the case of influenza, droplet precautions are sufficient, and assigning the client to a room with standard airflow is appropriate.

View Question and Answer

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

A nurse working in an emergency department is performing triage. To which of the following clients should the nurse assign priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is supervising an assistive personnel who is feeding a client who has dysphagia. Which of the following actions by the AP should the nurse identify as correct technique?

Correct Answer is C

Explanation

A nurse is teaching a newly licensed nurse about implementing droplet precautions for a client who has influenza. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is assisting with the orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and has difficulty completing care for his assigned clients. Which of the following interventions is appropriate?

A nurse enters a client’s room to witness an informed consent for a gastroscopy. The client states he does not understand the procedure. Which of the following actions should the nurse take?

A nurse has just completed assessment charging on the electronic record for an assigned client. An assistive personnel who just measured the client’s vital signs asks to chart them while the nurse is still logged into the record. Which of the following actions should the nurse take?

A nurse is delegating care for a group of clients. Which of the following clients should the nurse assign to a licensed practical nurse?

A nurse is preparing to discharge a client who requires home oxygen. The equipment company has not yet delivered the oxygen tank. Which of the following actions should the nurse take?

A nurse manager observes an assistive personnel incorrectly transferring a client to the bedside commode. Which of the following actions should the nurse take first?

A nurse manager observes a licensed practical nurse who has a strong odor of alcohol on their breath. Which of the following actions should the nurse manager take?

A nurse is caring for a client who has cancer the client’s adult child asks the nurse for information about the client’s treatment plan. Which of the following responses should the nurse make?