A nurse is performing triage for a group of clients following a mass casualty incident (MCI). Which of the following clients should the nurse plan to care for first?

A client who has an open upper extremity fracture

A client experiencing a tension pneumothorax

A client who has full-thickness burns over 85% of their body

A client who has agonal respirations

Answer and Explanation

The Correct Answer is B

A. A client who has an open upper extremity fracture: While this is a serious injury, it is less critical compared to a tension pneumothorax in a triage setting.
B. A client experiencing a tension pneumothorax: This is a life-threatening condition that requires immediate intervention to relieve pressure on the lungs and restore adequate breathing.
C. A client who has full-thickness burns over 85% of their body: This is a severe condition with a high mortality risk, but in a mass casualty situation, a tension pneumothorax is prioritized for immediate care.
D. A client who has agonal respirations: Agonal respirations indicate severe distress, but the immediate need for intervention is to address conditions that can rapidly compromise life, such as a tension pneumothorax.

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Correct Answer is D

Explanation

A. Remove the dressing to inspect the wound: This could exacerbate the wound and increase the risk of air entering the pleural space. The priority is to manage the wound to prevent further complications.
B. Prepare to insert a central line: While a central line might be needed for severe fluid resuscitation or medication administration, addressing the immediate airway and breathing concerns is more urgent.
C. Raise the foot of the bed to a 90° angle: This position is not appropriate for managing a sucking chest wound and does not address the immediate respiratory needs.
D. Administer oxygen via nasal cannula: The client is showing signs of hypoxia and increased respiratory distress. Administering oxygen will help improve oxygenation and manage symptoms of hypoxia until further interventions can be taken.

A. Prepare the client for transfer to a facility with a hyperbaric chamber. B. Apply oxygen via a nonrebreather mask at 15 liters. C. Check the client's oxygenation level with a pulse oximeter. D. Administer intravenous (IV) fluids.

Correct Answer is B

Explanation

A. Prepare the client for transfer to a facility with a hyperbaric chamber: This may be required for severe cases of carbon monoxide poisoning, but immediate intervention with high-flow oxygen is essential first.
B. Apply oxygen via a nonrebreather mask at 15 liters: Carbon monoxide poisoning requires immediate high-flow oxygen to help displace carbon monoxide from hemoglobin. This is the first step in treatment to prevent further tissue hypoxia and complications.
C. Check the client's oxygenation level with a pulse oximeter: While important, it does not address the immediate need for high-flow oxygen to treat carbon monoxide poisoning.
D. Administer intravenous (IV) fluids: IV fluids may be necessary for supportive care but are not the priority for treating carbon monoxide poisoning. The immediate need is to provide high-flow oxygen.

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A nurse is performing triage for a group of clients following a mass casualty incident (MCI). Which of the following clients should the nurse plan to care for first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is B

Explanation

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