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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Mental status assessment involves evaluating a client's cognitive and emotional function.
B. Nutritional assessment involves evaluating a client's dietary intake and nutritional status.
C. An environmental health assessment involves assessing exposure to environmental hazards such as chemicals and pollutants.
D. Faith-based assessment involves exploring a client's religious or spiritual beliefs and practices.

A. Apply hydrating lotions. B. Sit in the sun for 10 min per day. C. Apply moist heat. D. Wash with plain soap and water

Correct Answer is A

Explanation

A. Applying hydrating lotions helps moisturize and soothe the skin, which can alleviate dryness and scaling after radiation treatment.
B. Sitting in the sun can exacerbate skin damage and should be avoided after radiation therapy.
C. Moist heat can increase skin irritation and is not recommended for soothing radiation-damaged skin.
D. Washing with plain soap and water is appropriate but should be done gently to avoid further irritation.

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A nurse is assisting with triaging clients following an explosion. Which of the following clients should the nurse identify as the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is interviewing a client and asks the client, "Have you or your family been exposed to any chemical liquids, fumes, lead, or unusual smells?" Which type of assessment is the nurse conducting?

Correct Answer is C

Explanation

After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions?

Correct Answer is A

Explanation

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