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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}
Explanation
- This prescription helps maintain oral hygiene and comfort, which is important during chemotherapy to prevent and manage mucositis.
- Routine daily temperature checks may not be necessary unless there are specific concerns about infection or fever.
- Placing the client in a private room can reduce the risk of infection, which is crucial due to the client's immunocompromised state from chemotherapy.
- Unless there is a specific medical indication (e.g., urinary retention), inserting an indwelling urinary catheter increases the risk of infection, which should be minimized in an immunocompromised client.
- Droplet precautions are typically used for respiratory infections transmitted by large droplets. Lung cancer itself does not typically require droplet precautions unless there is an active respiratory infection.
Correct Answer is D
Explanation
A. Clinical breast examinations are generally recommended every 1 to 3 years for women in their 20s and 30s and annually for women 40 and older. However, the emphasis has shifted towards mammography as a primary screening tool.
B. Routine screening for colorectal cancer typically begins at age 45 for average-risk individuals, not 40. Colonoscopies are generally recommended every 10 years if results are normal.
C. Mammograms are typically recommended to start at age 40 for average-risk women, with yearly screening starting at age 45 or 50 depending on guidelines.
D. Annual testing for fecal occult blood is a recommended screening method for colorectal cancer starting at age 45, as it helps detect blood in the stool which can be an early sign of colorectal cancer.
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