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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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Ensure the client's intake is greater than their output: This is incorrect. In continuous bladder irrigation, the output may exceed the intake because the irrigation fluid is used to flush the bladder. The focus should be on ensuring proper drainage and monitoring for clots or obstruction rather than ensuring intake exceeds output.
B. Monitor the client's urine output every eight hours: This is incorrect. Following a transurethral resection of the prostate with continuous bladder irrigation, urine output should be monitored more frequently to ensure the irrigation system is functioning properly and to assess for signs of bleeding or obstruction.
C. Remind the client he might feel a constant urge to void: This is correct. It is common for clients to experience a constant urge to void due to bladder irritation and the presence of the catheter.
D. Assess for manifestations of fluid volume deficiency: This is incorrect. The primary concern with continuous bladder irrigation is monitoring for signs of bleeding or obstruction rather than fluid volume deficiency. Fluid balance is monitored based on intake and output, but deficiency is less likely in this context.

A. A client who has a fractured fibula and tibia B. A client who has sustained a major burn to their upper torso and extremities C. A client who has a sprained ankle and laceration to the lower leg D. A client who has an open traumatic brain injury and agonal breaths

Correct Answer is D

Explanation

A. A client who has a fractured fibula and tibia: This is incorrect. While serious, this injury does not require immediate life-saving intervention and is generally categorized as less urgent.
B. A client who has sustained a major burn to their upper torso and extremities: This is incorrect. Although severe, if the client is stable and responsive, they may be categorized as yellow (delayed) unless there are immediate life-threatening complications.
C. A client who has a sprained ankle and laceration to the lower leg: This is incorrect. These injuries are considered less severe and would typically be tagged as green (minor).
D. A client who has an open traumatic brain injury and agonal breaths: This is correct. Agonal breaths and severe head injury indicate a need for immediate life-saving intervention, so this client should receive a red tag for the highest priority.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is 2 hours postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?

Correct Answer is C

Explanation

A nurse is performing triage on the incident scene for several clients following a mass casualty event. The nurse should assign a red tag to which of the following clients?

Correct Answer is D

Explanation

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