A nurse is assisting with triaging clients following an explosion. Which of the following clients should the nurse identify as the highest priority?
A conscious adult client who has second-degree burns on both lower legs; respiratory rate is > 30/min
A conscious adult client wearing a medic-alert diabetic bracelet, client reports feeling clammy and shaky.
An unconscious adult client who has a large head wound with gray matter exposed; absent respirations
An unconscious 6-month-old infant with no respirations, no visible injuries
The Correct Answer is A
A. In mass casualty triage, priority is given to clients who are salvageable with immediate intervention. This client is conscious (airway is intact) but has respiratory distress (RR > 30/min), suggesting potential inhalation injury or early shock. Prompt treatment can be life-saving.
B. This client is conscious but has symptoms potentially related to hypoglycemia rather than life-threatening injuries.
C. Unconscious adult with large head wound and exposed gray matter, absent respirations is unsalvageable; in triage terms, this client would be black tag (expectant). Immediate care will not change survival.
D. Unconscious 6-month-old infant with no respirations, no visible injuries is also considered unsalvageable without immediate resuscitation; triage prioritizes those with highest likelihood of survival.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
A. Docusate sodium suppositories are commonly used to prevent constipation, which is important postoperatively, especially if the client is experiencing decreased bowel sounds and reports feeling bloated.
B. Ice application can help reduce swelling (edema) in the scrotal and penile area, which is noted in the client's assessment. This can help alleviate discomfort and promote healing.
C. Antispasmodic medications can help manage bladder spasms, which are common postoperatively due to the presence of an indwelling urinary catheter and continuous bladder irrigation.
D. While changing positions is important to prevent complications like pressure ulcers and promote comfort, specifically placing the client in a sitting position while in bed may not be necessary and could potentially interfere with postoperative recovery and comfort.
E. Teaching the client how to use a leg bag for urinary drainage is important, especially if the client will be discharged with a catheter. This education ensures the client can manage their urinary drainage system effectively.
Correct Answer is ["125"]
Explanation
To calculate the infusion rate for an IV, the total volume to be infused (in this case, 1000 mL) is divided by the total time of infusion (8 hours). So, the calculation would be 1000 mL divided by 8 hours, which equals 125 mL per hour.
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