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 D
Explanation
a. Review the chart for nonrestraint alternatives for agitation:
This action involves assessing the client's history, current condition, and any documented alternatives to restraints for managing agitation. While exploring nonrestraint interventions is important, addressing the immediate issue of inappropriate restraint use should take precedence.
b. Inform the unit manager:
Notifying the unit manager about the incident is important for escalating the situation and involving higher-level management in addressing the inappropriate use of restraints. However, before escalating, the immediate needs of the client should be addressed.
c. Speak with the AP about the incident:
Engaging in a conversation with the assistive personnel (AP) who applied the restraints allows for clarification of the situation, identification of any misunderstandings or training needs regarding restraint use, and immediate removal of the restraints if necessary. However, ensuring the client's safety should be the first priority.
d. Remove the restraints from the client’s wrist:
In situations where restraints are applied without a prescription or appropriate authorization, it is crucial to remove the restraints promptly to prevent potential harm to the client. However, it is essential to address the root cause of the inappropriate use of restraints and ensure that the client receives appropriate care and monitoring following restraint removal.
Correct Answer is B
Explanation
a. Advise him to complete less time-consuming tasks first:
This intervention may be helpful in prioritizing tasks and ensuring that essential care is provided in a timely manner. However, it does not address the underlying issue of difficulty focusing and may not address the root cause of the problem.
b. Recommend that he take time to plan at the beginning of his shift:
Planning at the beginning of the shift is essential for organizing tasks and prioritizing care. This intervention may help the newly licensed nurse improve their time management skills and focus by providing a structured approach to their work.
c. Offer to provide care for his clients while he takes a break:
While taking breaks is important for maintaining focus and preventing burnout, offering to provide care for his clients may not address the underlying issue of difficulty focusing and completing tasks. Additionally, taking over his tasks may not encourage the newly licensed nurse to develop the skills needed to improve his performance.
d. Ask other staff members to take over some of his tasks:
Asking other staff members to take over some of his tasks may provide temporary relief, but it does not address the underlying issue or help the newly licensed nurse develop the skills needed to improve his performance.
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