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. Varicella-zoster requires airborne and contact precautions due to the highly contagious nature of chickenpox (varicella) and shingles (zoster).
B. Vancomycin-resistant enterococcus (VRE) typically requires contact precautions to prevent transmission.
C. Pertussis is spread via respiratory droplets, so droplet precautions are necessary to prevent transmission.
D. Rotavirus is transmitted via the fecal-oral route and typically requires contact precautions.
Correct Answer is A
Explanation
A. Insert an indwelling catheter if the client has not voided in 3 hr: This task is within the LPN’s scope of practice, including sterile procedures such as catheterization. The RN retains the responsibility to evaluate the client’s overall status but may direct the LPN to insert a catheter under specific conditions.
B. Obtain the abdominal girth now and every 4 hr: This is a non-sterile, routine measurement and would be more appropriately assigned to assistive personnel rather than an LPN.
C. Assess and document the level of consciousness every hour: Assessment of neurological status requires RN-level clinical judgment, particularly in clients at risk for hepatic encephalopathy.
D. Measure the amount of gastric drainage every 2 hr: Although within an LPN’s scope, this task is repetitive and routine and may be more appropriate for assistive personnel under supervision.
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