Which client should receive immediate intervention based on the following details?
Client with a sucking chest wound, conscious, blood pressure 88/58 mm Hg, heart rate 115/min, and red tag observed.
Client with a significant penetrating head wound, unconscious with irregular breathing pattern, and black tag observed.
Client with superficial lacerations to the left arm and left lower leg, occlusive dressing in place, tearful, blood pressure 118/78 mm Hg, and green tag observed.
Client with closed left lower leg injury, air cast in place, pain reported as 9 on a 0 to 10 numeric pain scale, and yellow tag observed.
The Correct Answer is A
Choice A rationale
Sucking chest wounds impair oxygenation, posing a direct threat to life. Signs of shock (88/58 mm Hg, heart rate 115/min) demand immediate intervention. Red tag classification reflects life-threatening but treatable conditions needing priority care.
Choice B rationale
Significant penetrating head wounds with irregular breathing indicate brainstem damage, which usually leads to poor outcomes. Black tag assignment denotes expectant management due to un-survivable injuries.
Choice C rationale
Superficial lacerations with stable vitals (118/78 mm Hg) and occlusive dressing in place ensure no life-threatening issues. Green tag indicates minimal care urgency, requiring no immediate intervention.
Choice D rationale
Closed lower leg injuries causing severe pain do not compromise airway, breathing, or circulation. Yellow tag classification reflects delayed medical needs, prioritizing resources for more critical cases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Sterile water prevents contamination and maintains the client’s safety during administration, reducing the risk of introducing pathogens. It ensures proper medication dissolution for smooth NG tube flow.
Choice B rationale
Mixing medications together increases the risk of drug interactions, altering pharmacokinetics or pharmacodynamics, potentially causing side effects. It is unsafe for administering via an NG tube without compatibility checks.
Choice C rationale
Sublingual medications are designed for absorption through oral mucosa, bypassing first-pass metabolism. Crushing alters this route, reducing effectiveness. They should not be crushed or administered via NG tube.
Choice D rationale
Flushing with only 5 mL of saline is insufficient to clear residue, risking medication clogging. Standard practice suggests using at least 15-30 mL to ensure patency and avoid tube obstruction.
Correct Answer is A
Explanation
Choice A rationale
A bed alarm is a safety device that alerts staff when a client is attempting to get out of bed, reducing the risk of falls while maintaining the client’s autonomy and dignity.
Choice B rationale
Maintaining the bed in the lowest position minimizes fall risk upon exiting the bed, but it alone does not provide proactive monitoring, thus limiting its preventive effectiveness in dementia clients.
Choice C rationale
Vest restraints physically restrict movement and are associated with risks like pressure injuries or decreased circulation. They are considered a last resort and not routinely recommended for dementia clients.
Choice D rationale
Sedatives increase fall risk due to drowsiness and cognitive impairment, which could exacerbate symptoms in dementia. They are not the preferred intervention for safety concerns in this context.
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