A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care?

A client who has severe head injuries, respiratory rate 6/min, and is unresponsive

A client who has a simple fracture of the femur, multiple scratches on both legs, and is crying hysterically

A female who is pregnant at 20 weeks of gestation, has multiple cuts and abrasions, and is walking around

A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site

Answer and Explanation

The Correct Answer is D

Choice A Reason: This is incorrect because this client has signs of brain death, such as severe head injuries, low respiratory rate, and unresponsiveness. The nurse should tag this client as black, which means deceased or expectant.

Choice B Reason: This is incorrect because this client has non-life-threatening injuries, such as a simple fracture and scratches. The nurse should tag this client as green, which means minor or delayed care.

Choice C Reason: This is incorrect because this client has minor injuries and is able to walk around. The nurse should tag this client as green, which means minor or delayed care.

Choice D Reason: This is correct because this client has a life-threatening condition called tension pneumothorax, which requires immediate care. This client has a life-threatening condition called tension pneumothorax, which is caused by air leaking into the pleural space and compressing the lung and the heart. This can lead to respiratory failure, cardiac arrest, and death if not treated immediately. The hissing sound indicates that air is escaping from the lung through the wound. The nurse should tag this client as red, which means immediate care is needed.

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Correct Answer is ["B","C","D","E"]

Explanation

Choice a) is incorrect because nausea is not a common manifestation of ARF. Nausea is a sensation of discomfort in the stomach that may or may not lead to vomiting. Nausea can be caused by many other conditions, such as gastroenteritis, motion sickness, or pregnancy.

Choice b) is correct because severe dyspnea is a common manifestation of ARF. Dyspnea is a subjective feeling of difficulty or discomfort in breathing. Severe dyspnea indicates that the client is not getting enough oxygen and may have low blood oxygen levels (hypoxemia) or high carbon dioxide levels (hypercapnia).

Choice c) is correct because headache is a common manifestation of ARF. Headache is a pain or discomfort in the head, scalp, or neck. Headache can be caused by high carbon dioxide levels (hypercapnia), which can affect the blood vessels and nerves in the brain.

Choice d) is correct because a decreased level of consciousness is a common manifestation of ARF. Level of consciousness is a measure of how alert and oriented a person is. A decreased level of consciousness can be caused by low blood oxygen levels (hypoxemia), high carbon dioxide levels (hypercapnia), or acid-base imbalance, which can aﬀect brain function and mental status.

Choice e) is correct because hypotension is a common manifestation of ARF. Hypotension is a condition in which the blood pressure is lower than normal. Hypotension can be caused by low blood oxygen levels (hypoxemia), which can impair heart function and reduce cardiac output.

A. pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg B. pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg C. pH 7.50, HCO3- 26 mEq/L, PaCO2 50 mm Hg D. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg

Correct Answer is D

Explanation

Choice A Reason: This is incorrect because these values indicate respiratory alkalosis, which is caused by hyperventilation or excess loss of carbon dioxide (PaCO2). Respiratory alkalosis increases the blood pH and decreases the HCO3- level.

Choice B Reason: This is incorrect because these values indicate metabolic alkalosis, which is caused by excess intake or retention of bases or loss of acids. Metabolic alkalosis increases the blood pH and the HCO3- level.

Choice C Reason: This is incorrect because these values indicate respiratory acidosis, which is caused by hypoventilation or excess retention of carbon dioxide (PaCO2). Respiratory acidosis decreases the blood pH and increases the HCO3- level.

Choice D Reason: This is correct because these values indicate metabolic acidosis, which is a common complication of chronic kidney disease. These values indicate metabolic acidosis, which is a common complication of chronic kidney disease. Metabolic acidosis occurs when the kidneys are unable to excrete excess acids or retain enough bicarbonate (HCO3-), which is a base that buﬀers the blood pH. As a result, the blood pH decreases and becomes more acidic. The normal range for blood pH is 7.35 to 7.45, for HCO3- is 22 to 26 mEq/L, and for PaCO2 is 35 to 45 mm Hg.

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A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

Correct Answer is D

Explanation

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