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During a mass casualty event, a nurse is caring for multiple clients. Which of the following clients is the nurse's priority?
- A. A client who received crush injuries to the chest and abdomen and is expected to die.
- B. A client who has a 4-inch laceration to the head.
- C. A client who has partial-thickness and full-thickness burns to his face, neck, and chest.
- D. A client who has a fractured fibula and tibia.
Correct Answer: C
Rationale: During a mass casualty event, the priority client for the nurse is the one with partial-thickness and full-thickness burns to the face, neck, and chest. Clients with severe burns in critical areas require immediate attention due to the potential for life-threatening complications such as airway compromise, fluid loss, and infection. Crush injuries and fractures, although serious, are generally less urgent in comparison and can be managed after addressing the burns. Therefore, the client with burns to the face, neck, and chest should be the nurse's priority over the other clients described.
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A healthcare professional is instructing an AP about caring for a client who has a low platelet count. Which of the following instructions is the priority for measuring vital signs for this client?
- A. Avoid measuring the client's temperature rectally.
- B. Count the client's radial pulse for 30 seconds and multiply it by 2.
- C. Count the client's respirations discreetly.
- D. Allow the client to rest for 5 minutes before measuring their BP.
Correct Answer: A
Rationale: The correct answer is to avoid measuring the client's temperature rectally. Rectal temperatures can cause bleeding in clients with low platelet counts. It is crucial to avoid invasive methods that could increase the risk of bleeding or discomfort. Choice B, counting the radial pulse, is not directly related to the risk of bleeding in a client with low platelet count. Choice C, counting respirations discreetly, is important for accuracy but is not the priority when considering the risk of bleeding. Choice D, letting the client rest before measuring blood pressure, is beneficial but is not the priority in preventing potential harm due to low platelet counts.
During an assessment, a healthcare professional observes significant tenting of the skin over an older adult client's forearm. What factor should the healthcare professional primarily consider as a cause for this finding?
- A. Thin, parchment-like skin
- B. Loss of adipose tissue
- C. Dehydration
- D. Diminished skin elasticity
Correct Answer: C
Rationale: Dehydration is the primary factor to consider in this scenario. Dehydration leads to decreased skin turgor and tenting, where the skin does not return to its normal position when pinched. While thin, parchment-like skin, loss of adipose tissue, and diminished skin elasticity can contribute to skin changes, they are not the primary cause of the significant tenting observed.
A nurse is counseling an older adult who describes having difficulty with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority?
- A. "I spent my whole life dreaming about retirement, and now I wish I had my job back."
- B. "It's been so stressful for me to have to depend on my child to help around the house."
- C. "I just heard my friend Al die. That's the third one in 3 months."
- D. "I keep forgetting which medications I have taken during the day."
Correct Answer: C
Rationale: The correct answer is C. The statement expressing the loss of friends is the priority issue as it indicates potential grief and emotional distress. Losing multiple friends within a short period can have a profound impact on an older adult's emotional well-being. Option A expresses regret but does not indicate an immediate emotional crisis. Option B focuses on stress related to dependence, which is important but not as urgent as coping with loss. Option D highlights a memory concern, which is significant but does not address the emotional impact of loss.
A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients?
- A. Members of the same religion may have varying feelings about their religion.
- B. A shared religion background does not guarantee identical beliefs.
- C. The same religious beliefs can influence individuals differently.
- D. Discussing differences and commonalities in beliefs may not always be relevant.
Correct Answer: C
Rationale: The correct answer is C. Religious beliefs can vary widely even among individuals of the same faith. It is essential for the nurse to recognize that the impact and interpretation of religious beliefs can differ from person to person. Choice A is incorrect as individuals within the same religion can have diverse feelings and interpretations. Choice B is incorrect because a shared religious background does not necessarily mean that individuals hold the same beliefs. Choice D is not the best course of action as discussing differences and commonalities in beliefs may not always be necessary or appropriate for providing care.
A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take?
- A. Check the catheter to see whether it is patent.
- B. Reassure the client that it is not possible for them to urinate.
- C. Re-catheterize the bladder with a larger-gauge catheter.
- D. Collect a urine specimen for analysis.
Correct Answer: A
Rationale: When a client with an indwelling catheter reports a need to urinate, the nurse's initial action should be to check the catheter for patency. This is crucial to ensure that the catheter is not blocked, twisted, or kinked, which could lead to urinary retention. Reassuring the client without assessing the catheter could delay necessary interventions. Re-catheterizing the bladder with a larger-gauge catheter should not be the first step unless catheter patency is confirmed as an issue. Collecting a urine specimen for analysis is important but not the immediate priority when the client reports a need to urinate.