An emergency department nurse triages a group of school children injured in a school bus crash. Which of the following children should the nurse have the provider evaluate first?
A child who has a forehead wound that is bleeding copiously
A child who has a compound fracture of the femur and is crying in pain
A child who reports diplopia and nausea and was unconscious at the scene but is now awake
A child who has several missing permanent teeth and a swollen, ecchymotic upper lip
The Correct Answer is C
A. A child who has a forehead wound that is bleeding copiously: While bleeding wounds require attention, they are not immediately life-threatening compared to other injuries described.
B. A child who has a compound fracture of the femur and is crying in pain: While painful, a
femur fracture is not typically immediately life-threatening unless it is causing severe bleeding or compromising circulation.
C. A child who reports diplopia and nausea and was unconscious at the scene but is now awake:
These symptoms suggest potential head trauma and require urgent evaluation to assess for intracranial injuries.
D. A child who has several missing permanent teeth and a swollen, ecchymotic upper lip: These injuries, while concerning, are not immediately life-threatening compared to the potential head injury described in option C.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Notifying the facility operator is important, but it is not the immediate priority when there is a fire endangering the client's safety.
B. While closing fire doors can help contain the fire, it is not the priority action after ensuring the client's immediate safety.
C. Turning off oxygen sources is crucial because oxygen can fuel the fire and cause it to spread rapidly. This action helps prevent the fire from worsening.
D. Putting out the fire with the appropriate extinguisher is important, but it comes after ensuring the fire's fuel source is cut off to prevent further escalation of the fire.
Correct Answer is A
Explanation
A. The water seal chamber should contain at least 2 cm of water to maintain the seal and prevent air from entering the pleural space. Only 1 cm of water is inadequate and requires intervention.
B. Tidaling, or fluctuation of water with respirations, is an expected finding and indicates that the system is functioning properly.
C. A suction chamber pressure of -20 cm H₂O is the standard setting for chest tube drainage systems and does not require intervention.
D. A drainage collection chamber that is one-third full is within normal limits and simply indicates the need to continue monitoring output.
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