An emergency department nurse triages a group of clients who were injured in a school bus crash. Which of the following clients should the nurse have the provider evaluate first?

A client who has a forehead wound that is bleeding copiously

A client who has a compound fracture of the femur and is crying in pain

A client who was unconscious at the scene and now reports diplopia and nausea

A client who has several missing teeth and a swollen, ecchymotic upper lip

Answer and Explanation

The Correct Answer is C

A. A client who has a forehead wound that is bleeding copiously. Although bleeding may appear dramatic, most scalp wounds bleed heavily and can be controlled with pressure. This is not immediately life-threatening if the client is stable.
B. A client who has a compound fracture of the femur and is crying in pain. This is a serious injury with risk for blood loss and infection, but the client is alert and stable enough to express pain, suggesting less immediate neurologic risk than other clients.
C. A client who was unconscious at the scene and now reports diplopia and nausea. This client likely has a head injury with signs of increased intracranial pressure or concussion (diplopia = double vision, nausea, and prior loss of consciousness). These are neurological red flags and require immediate evaluation to prevent deterioration.
D. A client who has several missing teeth and a swollen, ecchymotic upper lip. While painful and concerning, oral trauma without airway compromise is less urgent than potential brain injury.

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Correct Answer is B

Explanation

A. A client who has a fracture and is in balance suspension traction. This client is non-ambulatory and difficult to move quickly, so should not be evacuated first unless they are in immediate danger. They would require additional assistance and equipment to move safely.
B. A client who is ambulatory and receiving oxygen. This client is able to walk independently and can evacuate with minimal assistance, even while on oxygen. Evacuating ambulatory clients first helps clear the area quickly and frees up staff to assist less mobile clients.
C. A client who uses a wheelchair and is confused. While this client needs help due to confusion and mobility limitations, they are not the priority for first evacuation unless in immediate danger. They require more time and assistance.
D. A client who is bedridden and wears a hearing aid. This client is non-ambulatory and may have communication challenges, which makes evacuation more complex. They would be evacuated after ambulatory clients for safety and efficiency.

A. Schedule the client for an aPTT test. B. Collect a blood sample from the client for a direct Coombs test. C. Monitor the client for uterine contractions. D. Administer Rho(D) Immune globulin if the client is Rh positive.

Correct Answer is C

Explanation

A. Schedule the client for an aPTT test. An aPTT (activated partial thromboplastin time) test is used to monitor heparin therapy and is not relevant following an amniocentesis unless the client has a known bleeding disorder, which is not indicated here.
B. Collect a blood sample from the client for a direct Coombs test. The direct Coombs test is typically performed on newborns, not the mother, to detect antibodies attached to red blood cells. It is not a routine part of post-amniocentesis care.
C. Monitor the client for uterine contractions. After an amniocentesis, it is essential to monitor for signs of preterm labor, including uterine contractions. The procedure can irritate the uterus and potentially trigger contractions, especially at 34 weeks gestation.
D. Administer Rho(D) Immune globulin if the client is Rh positive. Rho(D) Immune globulin is given to Rh-negative clients after procedures like amniocentesis to prevent isoimmunization. It is not indicated for Rh-positive individuals.

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An emergency department nurse triages a group of clients who were injured in a school bus crash. Which of the following clients should the nurse have the provider evaluate first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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