A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first?
A client who has a small circular partial-thickness burn of the left calf.
A client who has severe respiratory stridor and a deviated trachea.
A client who has a splinted open fracture of the left medial malleolus.
A client who has a massive head injury and is experiencing seizures.
The Correct Answer is B
Choice A reason: A Client Who Has a Small Circular Partial-Thickness Burn of the Left Calf
A small circular partial-thickness burn of the left calf is considered a minor injury in the context of a mass casualty event. This type of injury does not pose an immediate threat to life and can be managed after more critical cases are addressed. In mass casualty triage, patients with minor injuries are often categorized as “green” or “minimal” and are treated last.
Choice B reason: A Client Who Has Severe Respiratory Stridor and a Deviated Trachea
A client with severe respiratory stridor and a deviated trachea should be assessed first. These symptoms indicate a potential airway obstruction, which is a life-threatening condition requiring immediate intervention. In mass casualty triage, patients with compromised airways are given the highest priority and are categorized as “red” or “immediate” because their condition is critical and requires urgent medical attention.
Choice C reason: A Client Who Has a Splinted Open Fracture of the Left Medial Malleolus
A splinted open fracture of the left medial malleolus is a serious injury but not immediately life-threatening if properly splinted. This client would be categorized as “yellow” or “delayed” in mass casualty triage, meaning they require medical attention but can wait until more critical patients are stabilized.
Choice D reason: A Client Who Has a Massive Head Injury and Is Experiencing Seizures
A client with a massive head injury and experiencing seizures is in a critical condition. However, in the context of mass casualty triage, the immediate priority is to secure the airway, breathing, and circulation. While this client is in dire need of medical attention, the presence of severe respiratory stridor and a deviated trachea in another client takes precedence due to the immediate threat to life.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The Health Care Proxy Does Not Go Into Effect Until I Am Incapable of Making Decisions
This statement is correct. A health care proxy, also known as a durable power of attorney for health care, only becomes active when the individual is no longer capable of making their own medical decisions. Until that point, the individual retains full control over their health care choices1.
Choice B reason: I Have to Choose a Family Member as My Health Proxy
This statement indicates a need for clarification. It is not necessary to choose a family member as a health care proxy. An individual can select any trusted person, whether a family member or a friend, to act as their health care proxy. The most important factor is that the chosen person understands the individual’s wishes and is willing to advocate for them2.
Choice C reason: I Can Change Who I Designate as My Health Care Proxy at Any Time
This statement is correct. An individual can change their designated health care proxy at any time, as long as they are still capable of making their own decisions. It is important to ensure that any changes are documented properly and that all relevant parties are informed of the change3.
Choice D reason: If I Become Incapacitated, End-of-Life Choices Will Be Made by My Proxy
This statement is correct. If an individual becomes incapacitated and is unable to make their own medical decisions, the health care proxy will step in to make decisions on their behalf, including end-of-life choices. The proxy should be well-informed about the individual’s preferences and values to make decisions that align with their wishes4.
Correct Answer is B
Explanation
Choice A reason:
Advising that the largest meal of the day should be in the evening is not typically recommended for clients with a colostomy. It is generally better to have smaller, more frequent meals throughout the day to aid digestion and reduce the risk of discomfort.
Choice B reason:
Eating yogurt can indeed help decrease the amount of gas. Yogurt contains probiotics, which can aid in digestion and reduce gas production. This is a beneficial dietary choice for clients with a colostomy.
Choice C reason:
Carbonated beverages are not recommended for controlling odor. In fact, they can increase gas production and lead to bloating, which can be uncomfortable for clients with a colostomy.
Choice D reason:
There is no need to eliminate pasta from the diet to prevent loose stools. Instead, clients should focus on a balanced diet that includes low-fiber foods initially and gradually reintroduce other foods while monitoring their effects.
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