A nurse is the triage officer in the emergency department during a disaster when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?
An unconscious adult client who has no respirations, capillary refill is > 2 seconds, and paramedics have already tried to reposition airway without results
A conscious adult client who has a broken tibia, blood pressure of 160/90 mm Hg, and heart rate of 118 beats per minute
An unconscious adult client who has a sucking chest wound, SpO2 of 85%, and capillary refill of < 2 seconds
A conscious adult client who reports shortness of breath, has a respiratory rate of 24/min, and capillary refill of <2 seconds
The Correct Answer is C
C. The unconscious adult client with a sucking chest wound and low SpO2 (85%) is in immediate need of intervention. A sucking chest wound is a life-threatening injury that can lead to respiratory distress and compromised oxygenation. This client requires immediate attention to address the chest wound and improve oxygenation.
A. The unconscious client with no respirations and an ineffective airway attempt is likely beyond rescue, making them lower priority compared to those with potentially reversible conditions.
B. The conscious client with a broken tibia and elevated vital signs is stable enough to be seen after more critical cases are addressed.
D. The conscious client with shortness of breath and a high respiratory rate is concerning but not as immediately life-threatening as a client with a sucking chest wound.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Pain-relieving medications may be appropriate for symptom management but do not address the need for diagnosis or treatment of gonorrhea exposure.
B. A basic metabolic panel (BMP) is not relevant to the diagnosis or management of gonorrhea. Testing for sexually transmitted infections (STIs) requires specific diagnostic tests.
C. Obtaining information about the client's recent sexual experiences is crucial for assessing risk factors, guiding testing, and determining appropriate treatment for gonorrhea.
D. A pelvic ultrasound is not typically the initial step in managing gonorrhea exposure. It might be used to assess complications but is not relevant for initial assessment or treatment.
Correct Answer is B
Explanation
A. Epinephrine IM injection is not appropriate in this scenario, as it is typically reserved for treating anaphylactic shock. It is not used for septic shock where hypotension persists after fluid resuscitation.
B. Norepinephrine IV infusion is the correct choice. It is the first-line vasopressor in septic shock management when a fluid bolus does not adequately raise blood pressure. Norepinephrine works by constricting blood vessels, thereby increasing vascular resistance and blood pressure.
C. Dobutamine IV infusion might be considered if there is evidence of myocardial dysfunction or if additional inotropic support is necessary. However, it is not the immediate next step following fluid resuscitation when addressing persistent hypotension in septic shock.
D. Dexamethasone IV injection is not indicated for treating septic shock directly. It may be used in other contexts, such as treating adrenal insufficiency or reducing inflammation, but it does not play a role in immediate blood pressure management in septic shock.
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