Prioritization question - need help with rationale

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152 Posts

I would go with d. Tetanus would be the highest priority at the moment.

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Specializes in Forensic Psych.

I think the odds of a patient needing a blood transfusion from a nail sized hole are pretty darn slim.

One of the first things that would be done with a wound like that would be giving a tetanus shot if the pt wasn't current, so I'd go with D as a priority. In fact I had a pt in the ER last week that did something similar. One of the very first things he was asked was if he was current on his shots.

Even if alcohol use delays the tetanus shot, you still need to know if the pt even needs one before the alcohol would even become a concern, no?


10 Posts

Thank you very much, everyone, for sacrificing your own time to research this matter or to provide me with your precious input. Prioritization questions are always difficult to tackle, especially when you need more knowledge of protocols and procedures. I appreciate each and every individual contributions in the highest.

In the ER, it's the tetanus! Dirty puncture = tetanus.

Blood type: Are they massively bleeding from the nail? Not unless it hit an artery!

Blood alcohol: nice to know, but treat patient first.

Voiding time: may be inaccurate due to alcohol, also not significant at this time.

Esme12, ASN, BSN, RN

1 Article; 20,908 Posts

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

I agree with grn tea.......when was the last tetnas. What was the answer?

nurseprnRN, BSN, RN

1 Article; 5,114 Posts

Yeah, blood type but only because I'm applying the "Test Strategy Rules". They only put pertinent information in the question so you have to ask "why do I care if he's been drinking?" Alcohol is a blood thinner and while I don't think a nail gun injury to the hand is going to require a transfusion, the question is setting it up that way. In the real world however, none of this are particularly important assessments to make other than the tetanus question. In fact, I'd say asking him if the wound was intentional would be the priority question and if he had plans of hurting himself or others.

1) "Alcohol is a blood thinner"?? Alcohol is not an anticoagulant. People with very bad livers can have deficient clotting factors, but they aren't usually still working if they're that sick and there's no other information here to make you suspect this. Don't read too much into the question.

Please, everyone, do not use the term "blood thinners," because it makes patients think of water in the milk or turpentine in the paint. Anticoagulants do not thin the blood, they decrease its clotting ability. I know you will hear other nurses and even doctors use this term speaking to patients because they think "anticoagulant" is a big scary/confusing word. They are wrong to do so. I've heard people say that they are always cold when they take warfarin because they have thin blood. Obviously not the case, so someone has missed the boat on patient teaching and this resulted in confusion they tried to avoid.

Think about your patient teaching: If you are teaching someone about his anticoagulant medications, how do you reinforce the idea of why he takes them if he thinks it has to do with thinning blood and not making clots?

"Your heartbeat is irregular, atrial fibrillation, and that increases the chances that a blood clot will form in your heart. (Or, "You have a tendency to form clots in the deep veins in your leg. These could travel to your heart and lungs and be dangerous.") So we give you this medication to decrease your clotting. We test your blood every X days/weeks/months to see that the dose is still correct, by looking at how long your blood takes to clot. While you are taking this medication, called an "anticoagulant," your blood will not clot as fast as normal, so you should avoid things that might result in injury like ..... You should look out for easy bruising or bleeding, or bleeding that doesn't stop, black in your stools or if you vomit blood; tell your healthcare provider right away."

Is that so hard? Get in the habit of doing it right in the first place and you won't have to change your language later.

2) There is no indication that this injury was intentional or that there is any reason to suspect that he would be a danger to others. People who self-mutilate are more often female (although there are some males who do cut), and they don't tend to use power tools at a workplace to do it. :roflmao:


4 Posts

What about blood alcohol level with regards to ability to consent for treatment? Wouldn't you need to know if he is able to consent before giving immunization or typing blood?

KelRN215, BSN, RN

1 Article; 7,349 Posts

Specializes in Pedi.
What about blood alcohol level with regards to ability to consent for treatment? Wouldn't you need to know if he is able to consent before giving immunization or typing blood?

If the client is coherent enough to have a conversation and tell you that he drank 3 beers over the course of 3 hours (which is not an excessive amount since your liver can metabolize one drink/hr), I'm doubting that he's so sloshed that he can't consent for treatment. There's nothing in this question that should lead you believe that he cannot... he presented to the ER for treatment, he was able to recall how the injury happened and what he was doing and he admits to how much he drank.

I agree with the majority... tetanus is your priority. A small puncture wound to the hand isn't going to result in massive blood loss requiring a transfusion, his BAL is more than likely irrelevant to his care and who cares when the last time he peed was?

nurseprnRN, BSN, RN

1 Article; 5,114 Posts

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

Esme12, ASN, BSN, RN

1 Article; 20,908 Posts

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

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.

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....


425 Posts

*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."

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