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 social worker is not the best choice for a referral for a client who is having difficulty walking following a stroke. A social worker can help the client with psychosocial issues, such as coping, support, and resources, but not with physical rehabilitation.
Choice B reason: A physical therapist is the best choice for a referral for a client who is having difficulty walking following a stroke. A physical therapist can assess the client's mobility, strength, balance, and coordination, and provide exercises and interventions to improve the client's gait and function.
Choice C reason: An occupational therapist is not the best choice for a referral for a client who is having difficulty walking following a stroke. An occupational therapist can help the client with activities of daily living, such as dressing, bathing, and eating, but not with walking.
Choice D reason: A dietitian is not the best choice for a referral for a client who is having difficulty walking following a stroke. A dietitian can help the client with nutritional needs, such as calorie intake, fluid balance, and dietary restrictions, but not with walking.
Correct Answer is C
Explanation
Choice A reason: A respiratory therapist is a health care professional who can provide education and assistance on the use and maintenance of the nebulizer, but not on the financial aspects of obtaining it. The nurse should collaborate with the respiratory therapist to ensure the parent understands how to administer the nebulized medications to the child.
Choice B reason: A pharmacist is a health care professional who can provide information and advice on the medications prescribed for the child, but not on the financial aspects of obtaining the nebulizer. The nurse should consult with the pharmacist to ensure the parent knows how to store and handle the medications safely.
Choice C reason: A social worker is a health care professional who can provide support and resources to the parent regarding the financial aspects of obtaining the nebulizer. The nurse should refer the parent to the social worker to explore options such as insurance coverage, payment plans, or assistance programs.
Choice D reason: Child protective services is an agency that investigates and intervenes in cases of child abuse or neglect. The nurse should not refer the parent to child protective services, as this could imply that the parent is intentionally harming or neglecting the child, which is not the case. The nurse should respect the parent's rights and dignity, and offer help and guidance.
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