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 A
Explanation
A. Surgical intervention is the most common and effective treatment for age-related cataracts. Cataract surgery involves the removal of the cloudy lens and replacement with an artificial intraocular lens, which can significantly improve vision.
B. Corticosteroid eye drops are not used to treat cataracts; they are generally prescribed for reducing inflammation in various eye conditions but do not address the lens opacity caused by cataracts.
C. Antioxidant supplements, beta-carotene, and selenium have been studied for their potential role in slowing the progression of cataracts, but they are not considered a primary treatment once cataracts have developed to the point of affecting vision.
D. Eyeglasses or magnifying lenses may help improve vision temporarily in the early stages of cataracts, but they do not treat the underlying cause and are not effective in advanced cases. Surgery remains the definitive treatment.
Correct Answer is D
Explanation
A. Malignant hypertension poses risks for other conditions but is not the primary risk factor for cardiogenic shock.
B. A stroke does not directly lead to cardiogenic shock, though it may have other significant complications.
C. Acute kidney injury affects renal function but is not the primary risk for cardiogenic shock.
D. A myocardial infarction (MI) can impair the heart's pumping ability, leading to cardiogenic shock. This is due to the damage to heart muscle that can severely impact cardiac output and blood pressure.
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