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. Urinary output: While important, urinary output is not the immediate priority over assessing vital signs and consciousness.
B. Blood pressure: This is the priority assessment post-operatively to monitor for signs of bleeding, shock, or other complications.
C. Pain level: Pain management is important but secondary to ensuring stable hemodynamics immediately post-surgery.
D. Level of consciousness: This is also crucial, but monitoring blood pressure is a more direct indicator of immediate postoperative stability and potential complications.

A. Instruct the client to change clothing before arriving. B. Inform the client that photographs of any injuries will be mandatory for a police report. C. Ask the client to repeat the information obtained during admission. D. Obtain a history of the incident from the client.

Correct Answer is D

Explanation

A. Instruct the client to change clothing before arriving: This is incorrect. The client should be advised to keep the clothing they were wearing during the assault as evidence, not to change them.
B. Inform the client that photographs of any injuries will be mandatory for a police report: This is incorrect. While photographs might be necessary for evidence, it is not appropriate to make such statements without discussing consent and the client's comfort first.
C. Ask the client to repeat the information obtained during admission: This is incorrect. Repeating information may be distressing for the client. The nurse should obtain the history in a sensitive and supportive manner without unnecessary repetition.
D. Obtain a history of the incident from the client: This is correct. Gathering a detailed history is important for appropriate care and forensic evidence collection. The nurse should do this in a compassionate and nonjudgmental manner, ensuring the client feels supported.

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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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