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
Explanation
A. Neutropenic clients have reduced immune function and are at increased risk of infection from exposure to crowds and potential pathogens.
B. Taking temperatures daily, not weekly, is important to monitor for signs of infection in neutropenic clients.
C. Mild exercise is generally encouraged but should be discussed with the healthcare provider to ensure safety and infection prevention.
D. Fresh fruits and vegetables are important for overall nutrition but should be washed thoroughly to reduce the risk of infection.
Correct Answer is D
Explanation
A. A patient with a blue tag indicates minor injuries or illness and can wait for treatment.
B. A patient with a black tag is typically deceased or expected to die and is not a priority for immediate assessment.
C. A patient with a yellow tag indicates delayed treatment needs and can wait while more urgent cases are addressed.
D. A patient with a red tag indicates critical and life-threatening injuries requiring immediate assessment and intervention.
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