A nurse is assisting with triaging clients after a mass casualty event. Which of the following clients should the nurse attend to first?
A client who has a splinted open fracture of the left medial malleolus.
A client who has a penetrating head injury and is experiencing seizures.
A client who has severe respiratory stridor and a deviated trachea.
A client who has a small circular partial-thickness burn of the left calf.
The Correct Answer is C
Choice A reason: An open fracture, while needing medical attention, is not immediately life-threatening. The client's condition is stable enough to wait while more critical cases are attended to.
Choice B reason: A penetrating head injury with seizures is a critical condition. However, ensuring a patent airway takes precedence in emergency situations. This client's seizures indicate serious brain injury, but the immediate threat to life, such as airway obstruction, must be prioritized.
Choice C reason: Severe respiratory stridor and a deviated trachea indicate a life-threatening airway obstruction. This client needs immediate attention to secure the airway and prevent respiratory failure. This is the highest priority because without a clear airway, the client will not survive long enough to benefit from other interventions.
Choice D reason: A partial-thickness burn, although painful and requiring treatment, is not immediately life-threatening. This client can safely wait while those with more critical needs are attended to.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Limiting fluid intake is not an appropriate intervention for labyrinthitis. Adequate hydration is important for overall health and should be maintained.
Choice B reason: The correct answer is b because labyrinthitis can affect the vestibular system, leading to dizziness and vertigo. Monitoring the client’s cardinal fields of vision helps assess for nystagmus, which is a common symptom of vestibular disorders.
Choice C reason: Encouraging ambulation is not advisable for clients with labyrinthitis, as it can increase the risk of falls and injury due to dizziness and imbalance.
Choice D reason: Ensuring the room is brightly lit is not necessary for the management of labyrinthitis and may not provide any therapeutic benefit.
Correct Answer is D
Explanation
Choice A reason: While a thallium scan can provide information about the heart's functional capacity, it is more specifically used to detect areas of the heart muscle that are not receiving adequate blood supply.
Choice B reason: A thallium scan does not identify heart rhythm disturbances. This is typically evaluated with an electrocardiogram (ECG) or Holter monitor.
Choice C reason: The size of the chambers of the heart is usually assessed through echocardiography or other imaging techniques, not a thallium scan.
Choice D reason: The correct answer is d because a thallium scan detects damage to the heart muscle by identifying areas with reduced blood flow, which may indicate ischemia or previous infarction.
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