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 A

Explanation

A. The stoma appears dark purple in color. This is a priority finding, as it may indicate impaired circulation or necrosis of the stoma tissue. A healthy stoma should appear pink or red and moist. A dark purple or black color requires immediate evaluation.
B. The colostomy has had no output. While it is important to monitor output, it is not unusual for a new colostomy to have minimal or no output in the first 24–48 hours post-op as bowel function returns.
C. The client refuses to look at the colostomy. This is a psychosocial concern and may indicate body image issues or denial, but it is not the most urgent issue in the immediate postoperative period.
D. The client reports a pain level of 6 on a scale from 0 to 10. Pain management is important, but a pain level of 6, while needing intervention, does not take priority over a potential vascular compromise of the stoma.

A. "You will feel your baby moving within the next month." B. "Hormone shifts often cause vulvar itching." C. "You should consume at least 3 liters of fluid each day." D. “Headaches are expected throughout pregnancy"

Correct Answer is C

Explanation

A. "You will feel your baby moving within the next month." Fetal movement, or quickening, is typically felt between 16 and 20 weeks of gestation. At 9 weeks, it is too early for the client to detect fetal movement.
B. "Hormone shifts often cause vulvar itching." Vulvar itching is not a common or expected symptom of early pregnancy and may indicate an infection, such as a yeast infection, rather than a normal hormonal change.
C. "You should consume at least 3 liters of fluid each day." Adequate hydration is essential during pregnancy to support increased blood volume, amniotic fluid, and metabolic processes. A daily intake of about 3 liters of fluid helps prevent dehydration and constipation.
D. “Headaches are expected throughout pregnancy." While headaches can occur, especially in the first trimester due to hormonal changes, persistent or severe headaches may indicate complications like preeclampsia and should not be considered a normal, ongoing expectation.

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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

A nurse is assessing a client who had a colostomy 24 hrs ago. Which of the following findings is the nurse's priority?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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