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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect. The balloons should not be deflated without a physician's order, as this can cause rebleeding or aspiration.
Choice B Reason: This is incorrect. The head of the bed should be elevated to 30 to 45 degrees to reduce pressure on the balloons and prevent gastric reflux.
Choice C Reason: This is correct. The nurse should monitor the client closely for signs of complications, such as airway obstruction, aspiration, or balloon rupture. The nurse should also keep scissors at the bedside to cut the tube and release the balloons in case of an emergency.
Choice D Reason: This is incorrect. The tube should not be suctioned, as this can damage the mucosa and cause bleeding. The nurse should only aspirate gastric contents through the gastric lumen to decompress the stomach.
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because the results are not within the expected reference range. The client's BUN, creatinine, and hematocrit are elevated, indicating dehydration or reduced renal perfusion.
Choice B Reason: This is correct because evaluating urine for amount and for specific gravity can help assess the client's hydration status and renal function. These actions can help assess the client's hydration status and renal function, which may be affected by nausea and vomiting. The client's BUN, creatinine, and hematocrit are elevated, indicating dehydration or reduced renal perfusion. The normal ranges for BUN are 7 to 20 mg/dL, for creatinine are
0.6 to 1.2 mg/dL, and for hematocrit are 38% to 50% for males. The nurse should monitor the urine output and specific gravity, which reflect the concentration and volume of urine. The normal range for urine output is 30 to 60 mL/hour, and for specific gravity is 1.005 to 1.030.
Choice C Reason: This is incorrect because collecting a urine specimen for culture and sensitivity is not indicated for this client. This action is used to diagnose urinary tract infections, which are not suggested by the client's symptoms or results.
Choice D Reason: This is incorrect because decreasing the IV fluid infusion rate and limiting oral fluid intake can worsen the client's dehydration and renal perfusion. The nurse should maintain adequate fluid intake and balance to prevent further complications.
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