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 C
Explanation
A. Applying a warm pack can increase the absorption of venom and worsen symptoms.
B. Applying a tourniquet can restrict blood flow and worsen local effects of the venom.
C. Removing the stinger by scraping it off with a knife blade is the correct method to prevent further venom injection.
D. Sucking the wound can introduce infection and is not recommended.
Correct Answer is D
Explanation
A. Whole blood is not specifically indicated in response to smallpox exposure.
B. Antibiotics may be used for certain biological agents but are not effective against viruses like smallpox.
C. Atropine is used for treating certain types of poisoning and nerve agent exposures, not for smallpox.
D. Vaccine is crucial in response to smallpox as it can prevent infection if administered shortly after exposure or at the onset of symptoms.
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