A triage nurse in an emergency department is caring for a group of clients. Which of the following clients should the nurse assess first?
Client who has a displaced femur fracture from a fall
Client who is experiencing severe vomiting and diarrhea with tachycardia
Client who is confused and has slurred speech
Client who has chemical burns covering 20% of the total body surface area
The Correct Answer is C
Choice A reason: A client who has a displaced femur fracture from a fall is a priority client, but not the highest priority. The nurse should assess the client for signs of bleeding, infection, nerve damage, and compartment syndrome, and provide pain relief and immobilization. However, the client's condition is not as urgent or life-threatening as the other clients.
Choice B reason: A client who is experiencing severe vomiting and diarrhea with tachycardia is a priority client, but not the highest priority. The nurse should assess the client for signs of dehydration, electrolyte imbalance, and shock, and provide fluid and electrolyte replacement and antiemetic medication. However, the client's condition is not as urgent or life-threatening as the other clients.
Choice C reason: A client who is confused and has slurred speech is the highest priority client, as these are signs of a possible stroke, which is a medical emergency. The nurse should assess the client for other signs of stroke, such as facial drooping, arm weakness, and vision problems, and initiate the stroke protocol, which includes calling for help, obtaining a CT scan, and administering thrombolytic therapy if indicated.
Choice D reason: A client who has chemical burns covering 20% of the total body surface area is a priority client, but not the highest priority. The nurse should assess the client for signs of airway injury, infection, and fluid loss, and provide wound care, pain relief, and fluid resuscitation. However, the client's condition is not as urgent or life-threatening as the other clients.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A client who reports shortness of breath and left neck and shoulder pain may have a cardiac problem, which is a serious condition. However, this client is not the highest priority, as the symptoms are not life-threatening at the moment.
Choice B reason: A client who has active bleeding from a puncture wound of the left groin area is the highest priority, as this client is at risk of hemorrhage, shock, and infection. The nurse should apply direct pressure to the wound, elevate the leg, and monitor the vital signs.
Choice C reason: A client who has a raised red skin rash on his arms, neck, and face may have an allergic reaction, which is a potential emergency. However, this client is not the highest priority, as the symptoms are not severe enough to indicate anaphylaxis.
Choice D reason: A client who reports right-sided flank pain and is diaphoretic may have a kidney stone, which is a painful condition. However, this client is not the highest priority, as the symptoms are not life-threatening unless there is an obstruction or infection.
Correct Answer is D
Explanation
Choice A reason: A client who has bipolar disorder and is exhibiting signs of hallucination is not the highest priority for treatment. The client may have a psychiatric emergency, but their condition is not life-threatening or unstable. The nurse should assess the client's safety and provide emotional support, but they can wait for further intervention.
Choice B reason: A client who has major burns over 75% of their body surface area is a high priority for treatment, but not the highest. The client has a serious injury that can cause shock, infection, and organ failure. The nurse should monitor the client's vital signs, fluid status, and wound care, but they can wait for a short time.
Choice C reason: A client who has two open chest wounds with a left tracheal deviation is a high priority for treatment, but not the highest. The client has a tension pneumothorax, which is a life-threatening condition that causes air to accumulate in the pleural space and compress the lung and the heart. The nurse should seal the wounds with an occlusive dressing and prepare for chest tube insertion, but they can wait for a few minutes.
Choice D reason: A client who has a neck injury and is unable to breathe spontaneously is the highest priority for treatment. The client has a respiratory emergency, which is the most urgent condition that requires immediate intervention. The nurse should establish an airway, provide oxygen, and stabilize the neck, as well as call for help and notify the provider.
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