Nokea
A triage nurse has these 4 clients arrive in the emergency department within a 15 minute period. Which client should the triage nurse send back to be seen first?
- A. A 2 month old infant with a history of rolling off the bed and has bulging fontanels with crying
- B. A teenager who got a singed beard while camping
- C. An elderly client with complaints of frequent liquid brown colored stools
- D. A middle aged client with intermittent pain behind the right scapula
Correct Answer: B
Rationale: A teenager who got a singed beard while camping. This client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling.
You may also like to solve these questions
A 14-year old with leukemia tells the nurse, 'All I really want to eat is frozen yogurt.' The nurse should:
- A. Explain the importance of eating a balanced diet
- B. Ask the dietician to talk with the client to find out which foods he prefers
- C. Ask the kitchen to send the yogurt
- D. Document the client's refusal to eat the diet as ordered
Correct Answer: C
Rationale: Providing the requested yogurt respects the client's preferences and encourages intake, which is critical in leukemia patients who may have reduced appetite.
The mother of a boy who has recently been diagnosed with sickle cell anemia is pregnant and asks the nurse if her unborn baby will have sickle cell anemia. What information should the nurse include in the answer?
- A. Sickle cell anemia is a contagious disease, but your child should no longer be communicable by the time the baby is born.
- B. When both parents are carriers, there is a 25% chance that each child will have sickle cell anemia.
- C. Your sons have a 50% chance of having sickle cell anemia, but daughters can only be carriers.
- D. The next child should be disease free, but additional children have a chance of being born with the disease.
Correct Answer: B
Rationale: Sickle cell anemia is autosomal recessive; if both parents are carriers, each child has a 25% chance of inheriting the disease, regardless of sex or birth order.
The nurse is caring for a 31-year-old gravida 2, para 1 woman who is in labor. The woman calls the nurse and says, 'My water has broken and I feel something between my legs.' The nurse looks and sees a loop of umbilical cord at the vaginal outlet. After signaling for help, what should the nurse do?
- A. Try to replace the cord with a sterile gloved hand
- B. Place the mother in knee-chest position
- C. Quickly apply manual pressure on the fundus
- D. Expect a rapid vaginal delivery
Correct Answer: B
Rationale: Knee-chest position relieves pressure on the prolapsed umbilical cord, maintaining fetal oxygenation until emergency delivery. Replacing the cord or pressing the fundus worsens the situation.
The physician has ordered O2 at 3 liters/minute for a client with emphysema. Which device will deliver the most precise level of oxygen prescribed for the client?
- A. Nasal cannula
- B. Partial rebreather mask
- C. Simple face mask
- D. Venturi mask
Correct Answer: D
Rationale: The Venturi mask will deliver the most precise level of oxygen for the client with COPD. Answer A is incorrect, because the client may lose oxygen through an open mouth. Answers B and C are incorrect, because they are not used to deliver oxygen to the client with COPD.
During an examination of a 2 year-old child with a tentative diagnosis of Wilm's tumor, the nurse would be most concerned about which statement by the mother?
- A. My child has lost 3 pounds in the last month.
- B. Urinary output seemed to be less over the past 2 days.
- C. All the pants have become tight around the waist.
- D. The child prefers some salty foods more than others.
Correct Answer: C
Rationale: All the pants have become tight around the waist. Increased abdominal girth is an early sign of Wilm's tumor.