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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "After 5 to 10 minutes when the breast is emptied, my baby should be removed from the breast." The breast is rarely fully emptied during a feeding. Infants should be allowed to feed on one side until they naturally release it, ensuring they receive the nutrient-rich hindmilk.
B. "Manually expressing my milk will decrease my milk supply." Manual expression, like breastfeeding, stimulates milk production. Regularly removing milk from the breasts actually helps maintain or increase supply, especially during periods of engorgement or separation.
C. “My baby should always start on the same breast when feeding.” Alternating the starting breast with each feeding ensures even stimulation and drainage of both breasts. Always starting on the same side could lead to engorgement or reduced supply in the unused breast.
D. “The more my baby is at the breast sucking the more milk I will produce.” Breast milk production is based on a supply and demand mechanism. The more frequently and effectively the baby nurses, the more milk the body is signaled to produce.
Correct Answer is C
Explanation
A. Decrease the maintenance infusion rate of IV fluid. Epidural anesthesia can cause hypotension, so IV fluids are often used to help maintain blood pressure. Reducing the fluid rate may increase the risk of hypotensive episodes.
B. Have protamine sulfate available at the bedside. Protamine sulfate is the antidote for heparin, not relevant to epidural anesthesia. It is not required in the management of epidural-related side effects.
C. Reposition the client side-to-side each hour. Frequent repositioning helps prevent pressure injuries, promotes fetal oxygenation, and encourages effective labor progression. It also aids in the distribution of the anesthetic agent.
D. Monitor the client for hypertension. Hypotension, not hypertension, is a common adverse effect of epidural anesthesia due to vasodilation and decreased peripheral resistance. Blood pressure should be monitored closely for drops.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.