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 A

Explanation

A. Flu-like symptoms: This is correct. Inhalation anthrax initially presents with flu-like symptoms, including fever, cough, and malaise. This early presentation can progress to severe respiratory distress and systemic illness.
B. Vesicles on the skin: This is incorrect. Vesicular lesions are more characteristic of diseases such as smallpox or chickenpox, not anthrax.
C. Respiratory failure: While respiratory failure can occur with advanced inhalation anthrax, it is a later-stage complication rather than an initial finding.
D. Flaccid paralysis: This is incorrect. Flaccid paralysis is not a typical symptom of anthrax exposure but may be associated with diseases such as botulism.

A. A 28-year-old client who has a history of pelvic inflammatory disease B. A 26-year-old client who is mobile post appendectomy C. A 38-year-old client who reports smoking one pack of cigarettes every day D. A 32-year-old client who has fibrocystic breast disease

Correct Answer is C

Explanation

A. A 28-year-old client who has a history of pelvic inflammatory disease: This is incorrect. While a history of pelvic inflammatory disease does not necessarily contraindicate oral contraceptive use, it should be assessed for any other potential complications or contraindications.
B. A 26-year-old client who is mobile post appendectomy: This is incorrect. Recent surgery, such as an appendectomy, is not a contraindication for oral contraceptives, provided the client is otherwise healthy.
C. A 38-year-old client who reports smoking one pack of cigarettes every day: This is correct. Smoking, especially in women over 35, is a contraindication for oral contraceptives due to the increased risk of cardiovascular events such as thrombosis.
D. A 32-year-old client who has fibrocystic breast disease: This is incorrect. Fibrocystic breast disease does not contraindicate the use of oral contraceptives.

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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 caring for a client who has been suspected of recent exposure to anthrax by inhalation. Which of the following findings would indicate the client has been exposed?

Correct Answer is A

Explanation

A nurse is reviewing contraception options for four clients. The nurse should identify that which of the following clients has a contraindication for receiving oral contraceptives?

Correct Answer is C

Explanation

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