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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. "If you have the procedure now, you won’t have to deal with pain and disability later."
This response dismisses the client's concerns about pain and focuses solely on the potential benefits of the surgery. It fails to address the client's apprehension and does not provide support or empathy. Furthermore, it oversimplifies the situation and may come across as dismissive of the client's feelings.
b. “I understand, and it’s not too late to change your mind.”
This response demonstrates empathy and validation of the client's concerns. It acknowledges the client's autonomy and gives them the option to reconsider without judgment or pressure. It encourages open communication between the nurse and the client, fostering a supportive environment.
c. “Why didn’t you discuss your concerns with your provider?”
This response may come across as accusatory or blaming, which can further distress the client. It does not offer immediate support or validation of the client's concerns. While discussing concerns with the provider is important, this response fails to address the client's immediate distress and need for reassurance.
d. “You’ll be fine. You’ll receive a prescription for pain medication.”
This response minimizes the client's concerns by reassurance without addressing the underlying issue. It also assumes that pain medication will resolve all concerns related to pain, which may not be the case for the client. Additionally, it overlooks the client's emotional needs and autonomy in decision-making.
Correct Answer is A
Explanation
a. “The client is in the radiology department for a chest x-ray.”
This information is relevant as it informs the oncoming nurse about the client's current location and the reason for the absence from the unit. It helps maintain awareness of the client's whereabouts and the ongoing diagnostic process.
b. “The client’s partner came to visit him 2 hrs. ago.”
While it's important to document visitor interactions in the client's chart, informing about a visit from 2 hours ago during a change-of-shift report may not be as pertinent to immediate patient care as other information. This detail can be communicated through other means, such as the client's chart or communication log.
c. “The client has routine vital signs prescribed.”is not as critical to include in the change-of-shift report because it is standard practice and does not provide specific, immediate information about the client’s current status or any changes that need to be monitored closely.
d. “The client is the president of a local bank.”
While interesting, this information is not relevant to the client's current medical condition or care plan. It does not contribute to the immediate care needs of the client and can be considered extraneous during a change-of-shift report.
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