Prioritization question - need help with rationale - page 3

by Crobert

Hi! I'm trying to find out which is the correct answer to the following prioritization question: A 30-year-old client is brought to an emergency trauma center with a hand injury from a nail gun sustained while remodeling an... Read More


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    Quote from Crobert
    GrnTea, thank you so much for taking the time and trouble to provide me with rationales for why we would or would not do the activities listed under my question. As for the possible systemic reaction to the tetanus toxoid in persons with excessive alcohol consumption, I found the information on the website of the Centers for Disease Control and Prevention (there is a general immunization recommendations document there).
    I'm not seeing that at all in their discussion of tetanus immunization here: CDC - Pinkbook: Tetanus Chapter - Epidemiology of Vaccine-Preventable Diseases
    KelRN215 and Esme12 like this.
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    I have given TD to many intoxicated patients...I have NEVER seen a problem develop. But I have seen a Tetnas infection many years ago....I will NEVER forget it.......a 20yo construction worker with a nail injury to their heel. There was a bad batch of Tetnas vaccinations....he died.
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    Quote from Crobert
    Hi! I'm trying to find out which is the correct answer to the following prioritization question:

    A 30-year-old client is brought to an emergency trauma center with a hand injury from a nail gun sustained while remodeling an old barn. there is a strong odor of alcohol and the client admits to having three beers during a 3-hour period. Which assessment findings are most important for the nurse to evaluate FIRST?

    a. blood type
    b. time of last voiding
    c. current blood alcohol level
    d. date of last tetanus immunization

    I would also appreciate your rationale. Thank you in advance!

    The answer would be D. date of last tetanus shot , rationale is that after cleaning up the wound area , doctor will be ordering the tetanus shots , nail injury does not often need sutures for it would only by a puncture wound not unless the nail hits and breaks a bone in the hand, blood lost will be minimal , no need for blood transfusion, blood alcohol may be your second choice, so doctor may prescribe proper medication that will take effect even if patient is under influence of liquor...... also as an advice in answering such questions, think what a nurse should do and can do in such situations without by-passing doctors possible orders.. answer questions only within the boundaries of a nurses duties....
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    *Putting on NCLEX cap and visor*

    This being a priority question (with inclusion of the word, FIRST)....definitely D. GrnTea provided great rationale!

    Worry about what the problem is right at this moment....which is "a hand injury from a nail gun sustained while remodeling an old barn."
    Last edit by begosh on Jan 28, '13
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    I agree that is D. Also, remember to not read into the question or to add more information to fit in the answer that you think it is. If there is only one thing that you need to do for this patient, what will it be? The most important thing will be to assess if the patient has had a tetanus shot and when was it. The rest can wait.
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    I have friends who know all the information being taught but still struggle grade-wise because they say they over think questions. I finally get it after reading this thread!
    If you sit and think about each answer long enough you can probably halfway rationalize why every single answer could be correct.


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