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 C

A. This client has significant burns but is conscious and breathing, indicating adequate airway and respiratory effort.
B. This client is conscious but has symptoms potentially related to hypoglycemia rather than life-threatening injuries.
C. This client is unconscious with a severe head injury and absent respirations, indicating a compromised airway and immediate life-threatening condition.
D. This infant is unconscious with no respirations, requiring immediate attention but is not as urgent as the client with the severe head injury and compromised airway.

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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.

A. Prepare a 60-mL syringe with saline. B. Assist with intubation of the patient. C. Give first dose of activated charcoal. D. Insert a large-bore orogastric tube.

Correct Answer is B

Explanation

A. Preparing a 60-mL syringe with saline may be necessary for gastric lavage but is not the first action.
B. For an unconscious patient who has ingested a significant quantity of lorazepam, securing the airway is the most critical first step to prevent aspiration and ensure the patient can breathe. Therefore, the nurse should assist with intubation of the patient.
C. The initial step is to ensure that the client’s airway is secured through intubation before administration of activated charcoal.
D. Inserting a large-bore orogastric tube may be necessary for gastric lavage but typically follows administration of activated charcoal.

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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

When requested to plan the response to the potential use of smallpox as a biological weapon, what should the emergency department (ED) nurse manager expect to obtain?

Correct Answer is D

Explanation

Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first?

Correct Answer is B

Explanation

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