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 A
Explanation
a. "I should encrypt personal health information when sending emails."
This statement indicates an understanding of the importance of protecting confidential information during electronic communication. Encrypting personal health information in emails adds an extra layer of security to prevent unauthorized access.
b. "I can use another nurse’s password as long as I log off after using the computer."
This statement is incorrect and demonstrates a lack of understanding of client confidentiality. Sharing passwords is a violation of security policies and compromises the confidentiality of client information. Each nurse should have their unique login credentials to ensure accountability and traceability.
c. "I should discard personal health information documents in the trash before leaving the unit."
This statement is incorrect. Discarding personal health information in an unsecured manner, such as in the regular trash, can lead to unauthorized access and a breach of confidentiality. Proper disposal methods, such as shredding or using secure disposal containers, should be followed to protect sensitive information.
d. "I can post the client’s vital signs in the client’s room."
This statement is incorrect. Posting client information, including vital signs, in a public area like the client's room violates confidentiality. Personal health information should be shared only with authorized individuals involved in the patient's care and through secure communication methods. Posting such information in a public space compromises the client's privacy.
Correct Answer is D
Explanation
a. Involve the client’s partner to assist with the teaching session: While involving the client's partner can be helpful, it may not ensure effective communication if the partner also does not speak the same language as the client.
b. Incorporate gestures and hand signals when presenting information: This is an effective strategy to enhance communication with a client who speaks a different language. Non-verbal cues such as gestures and hand signals can help convey meaning and facilitate understanding.
c. Validate understanding by interpreting the client’s body language: Interpreting the client's body language can be helpful in assessing their level of understanding and engagement. However, it may not be sufficient for effective communication, especially if the client has questions or needs clarification.
d. Provide an interpreter when obtaining consent from the client: This is the most appropriate intervention. Using a professional interpreter ensures accurate communication between the nurse and the client, facilitating understanding and ensuring that the client's rights are upheld during the consent process.
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