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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A client who reports flank pain radiating to the groin: This could indicate renal colic or a kidney stone. While painful and concerning, it is not as immediately life-threatening as severe hemorrhage.
B. A client who has multiple fractures: Multiple fractures are serious but may not be as immediately life-threatening as severe hemorrhage or airway compromise.
C. A client with partial thickness burns to both hands: While painful and needing care, partial thickness burns are less critical compared to life-threatening hemorrhage.
D. A client who has a punctured femoral artery: This is an emergent situation because it involves severe hemorrhage. The femoral artery is a major artery, and puncture could lead to life-threatening blood loss and requires immediate intervention.
Correct Answer is ["56"]
Explanation
To calculate the infusion rate, we'll use the following formula:
Infusion rate (gtt/min) = (Volume to be infused (mL) / Time (min)) Drop factor (gtt/mL)
First, calculate the total time in minutes:
- 3 hours 60 minutes/hour = 180 minutes
Then, calculate the volume per minute:
- 500 mL / 180 minutes = 2.78 mL/min
Finally, multiply the volume per minute by the drop factor:
- 2.78 mL/min 20 gtt/mL = 55.6 gtt/min
Therefore, the nurse should set the manual IV infusion to deliver 56 gtt/min.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.