a nurse is caring for multiple clients during a mass casualty event which of the following clients is the nurses priority
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Nursing Elites

HESI LPN

Fundamentals of Nursing HESI

1. During a mass casualty event, a nurse is caring for multiple clients. Which of the following clients is the nurse’s priority?

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.

2. The nurse is caring for a client with a nasogastric (NG) tube. Which action should the nurse take to maintain patency of the tube?

Correct answer: A

Rationale: To maintain the patency of a nasogastric (NG) tube, it is essential to flush the tube with 30 ml of water before and after medication administration. This action helps ensure that the tube remains open and free from blockages. Flushing the tube prevents any medication residue from causing blockages, maintaining its patency. Choice B is incorrect because administering medication with food does not relate to maintaining tube patency. Choice C is incorrect as verifying tube placement by aspirating stomach contents is related to confirming correct tube placement, not maintaining patency. Choice D is also incorrect because diluting the medication with normal saline is not primarily aimed at maintaining the tube's patency.

3. During an eye irrigation for a client exposed to smoke and ash, which nursing action should receive the highest priority?

Correct answer: A

Rationale: The highest priority during an eye irrigation for a client exposed to smoke and ash is wearing gloves during the procedure. This action is crucial as it helps prevent contamination and protects both the client and the nurse. Using a sterile solution is important but not as critical as ensuring the nurse's safety by wearing gloves. Irrigating from the inner to the outer canthus and positioning the client's head properly are essential steps in eye irrigation, but they are not the highest priority in this scenario compared to ensuring infection control by wearing gloves.

4. To ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is a nurse manager functioning?

Correct answer: D

Rationale: The correct answer is D: Supervisor. In this scenario, the nurse manager is acting as a supervisor to oversee and ensure the newly licensed nurse performs the straight catheterization correctly, following protocols, and maintaining client safety. A supervisor role involves monitoring and guiding staff in their duties to ensure quality care. Choices A, B, and C are incorrect. A case manager typically manages a case load of clients but does not provide direct care like in this situation. Client educator and client advocate roles do not directly relate to supervising or overseeing a procedure being performed by another nurse.

5. A client is experiencing dehydration, and the nurse is planning care. Which of the following actions should the nurse include?

Correct answer: B

Rationale: Checking the client's weight daily is essential for monitoring fluid status in dehydration. Administering antihypertensives, notifying the provider of insufficient urine output, and encouraging ambulation are not primary interventions for managing dehydration. Administering antihypertensives may affect blood pressure, but it is not a direct intervention for dehydration. Notifying the provider of a urine output less than 30 mL/hr indicates oliguria, which is a sign of reduced kidney function rather than dehydration. Encouraging ambulation is a general nursing intervention and does not directly address the fluid imbalance associated with dehydration.

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