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 B

Explanation

A. Extreme abdominal pain with intercourse: This is less specific for endometrial cancer and more indicative of conditions such as pelvic inflammatory disease or endometriosis.
B. Postmenopausal bleeding: This is correct. Postmenopausal bleeding is a common symptom of endometrial cancer and warrants further evaluation.
C. Decreased white blood cell count: This is incorrect. Endometrial cancer does not typically present with a decreased white blood cell count; it may present with normal or elevated levels depending on the stage and presence of infection.
D. Bilateral swelling on the posterior of the vulva: This is incorrect. Swelling of the vulva is not characteristic of endometrial cancer but may be associated with other gynecological issues.

A. A client who has acute tonsillitis, is drooling, and has difficulty swallowing B. A client who sustained a deep laceration to their leg and is complaining of dizziness and weakness C. A client who has chronic obstructive pulmonary disease (COPD) with a pulse oximetry reading of 88% D. A client who has lower left abdominal pain and bloody stools

Correct Answer is A

Explanation

A. A client who has acute tonsillitis, is drooling, and has difficulty swallowing: This client is likely experiencing severe swelling or an airway obstruction, which requires immediate attention to ensure the airway is not compromised.
B. A client who sustained a deep laceration to their leg and is complaining of dizziness and weakness: While this client has concerning symptoms, airway compromise is prioritized in triage.
C. A client who has chronic obstructive pulmonary disease (COPD) with a pulse oximetry reading of 88%: This client is hypoxic and requires prompt intervention, but airway issues take precedence.
D. A client who has lower left abdominal pain and bloody stools: This client may have a serious condition but does not require as immediate intervention as a compromised airway.

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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

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