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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

Answer and Explanation

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.

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Correct Answer is B

Explanation

B. In a disaster situation, prioritizing care for clients with life-threatening emergencies is crucial to ensure that those in the most critical condition receive immediate attention. This aligns with triage principles and ensures that limited resources are used effectively.
A. While addressing ADLs is important, it is secondary to addressing life-threatening emergencies in a disaster scenario.
C. Discharging stable clients can help increase bed availability but should be considered after addressing immediate life-threatening needs.
D. Stocking additional supplies is necessary but should follow after ensuring that life-threatening conditions are managed.

A. Signs of sympathetic stimulation B. Hypertension C. Cool, moist skin D. Bradycardia

Correct Answer is D

Explanation

A. Neurogenic shock is characterized by the loss of sympathetic tone, leading to parasympathetic predominance. Therefore, signs of sympathetic stimulation, such as tachycardia or sweating, are not present.
B. Neurogenic shock typically causes hypotension, not hypertension, due to vasodilation and decreased systemic vascular resistance.
C. Cool, moist skin is more commonly seen in hypovolemic or septic shock due to peripheral vasoconstriction. In neurogenic shock, vasodilation leads to warm, dry skin.
D. Bradycardia is a hallmark of neurogenic shock due to unopposed parasympathetic stimulation resulting from the loss of sympathetic nervous system control.

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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?

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