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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Take naproxen for generalized discomfort
Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that can help with generalized discomfort. However, NSAIDs can cause fluid retention and worsen heart failure symptoms. They can also increase the risk of kidney damage and gastrointestinal bleeding, especially in individuals with heart failure. Therefore, it is generally advised to avoid NSAIDs and use alternative pain relief methods, such as acetaminophen, under the guidance of a healthcare provider.
Choice B reason: Notify the provider of a weight gain of 0.5 kg (1 lb) in a week
Monitoring weight is crucial for individuals with heart failure, as sudden weight gain can indicate fluid retention and worsening heart failure. A weight gain of 0.5 kg (1 lb) in a week is significant and should be reported to the healthcare provider immediately. This allows for timely intervention to adjust medications or other treatments to prevent further complications. Regular weight monitoring helps in early detection of fluid buildup and effective management of heart failure.
Choice C reason: Take diuretics early in the morning and before bedtime
Diuretics are commonly prescribed to help reduce fluid buildup in individuals with heart failure. However, taking diuretics before bedtime can lead to frequent nighttime urination, disrupting sleep. It is generally recommended to take diuretics early in the morning to minimize this issue. If a second dose is needed, it should be taken in the early afternoon to avoid nighttime disturbances.
Choice D reason: Exercise at least three times per week
Regular exercise is beneficial for individuals with heart failure as it helps improve cardiovascular health, increase stamina, and reduce symptoms. However, the exercise regimen should be tailored to the individual’s condition and capabilities. It is important to consult with a healthcare provider to develop a safe and effective exercise plan. Cardiac rehabilitation programs can also provide structured exercise guidance and support.
NGNs
Correct Answer is D
Explanation
Choice A reason:
A client with a tracheostomy tube attached to humidified oxygen is not typically at risk for hypokalemia. The primary concerns for these clients are maintaining a patent airway, preventing infection, and ensuring adequate humidification to prevent mucus plugging.
Choice B reason:
A client with an indwelling urinary catheter to gravity drainage is not specifically at risk for hypokalemia. The main risks for these clients include urinary tract infections and ensuring proper catheter care to prevent blockages.
Choice C reason:
A client with a chest tube to water seal is primarily at risk for complications related to the chest tube itself, such as infection, pneumothorax, or improper drainage. Hypokalemia is not a common risk associated with chest tubes.
Choice D reason:
A client with a nasogastric tube to suction is at risk for hypokalemia. Continuous suctioning can lead to the loss of gastric contents, which contain potassium, leading to a decrease in potassium levels in the body. This can result in hypokalemia, which needs to be monitored and managed appropriately.
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