A nurse is triaging clients who were involved in a commuter train crash. Which of the following clients should the nurse choose for transport to the emergency department first?
A client who has a fracture of the humerus with a 2+ radial pulse in the affected arm
A client who has full-thickness burn injuries over 30% of his total body surface area
A client who is exhibiting agonal respirations with fixed and dilated pupils
An ambulatory client who has a nosebleed and reports feeling dizzy
The Correct Answer is B
In a mass casualty incident (MCI) like a train crash, triage is based on the severity of injuries and likelihood of survival using the START (Simple Triage and Rapid Treatment) system. Clients are categorized as Immediate (Red), Delayed (Yellow), Minor (Green), or Expectant (Black).
A. A client with a humerus fracture and a 2+ radial pulse (Yellow - Delayed): The client is stable and not the highest priority for immediate transport.
B. A client with full-thickness burns over 30% TBSA (Red - Immediate): This client has life-threatening injuries requiring urgent treatment for airway support, fluid resuscitation, and burn care.
C. A client with agonal respirations and fixed, dilated pupils (Black - Expectant): This client is unlikely to survive even with treatment, so in an MCI, resources should be allocated to those with a higher chance of survival.
D. An ambulatory client with a nosebleed and dizziness (Green - Minor): This client is walking wounded and can wait for medical care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C, "An increase in client falls at home." A quality improvement committee is responsible for identifying and addressing areas in need of improvement in client care. Among home health clients, falls are a common cause of injury, which can lead to hospitalizations or even death. Therefore, it is essential to address this issue by examining the data and identifying trends to establish interventions to prevent falls. The committee can evaluate whether proper assessments have been completed, including a home safety evaluation, medication review, and the use of mobility aids, to prevent falls. The committee can also review the use of interventions, such as physical therapy or occupational therapy, to improve mobility and strength, and education for clients, caregivers, and family members to promote safety in the home environment. By addressing the increase in client falls, the committee can improve the quality of care provided to home health clients and reduce the risk of falls and injuries.
Correct Answer is D
Explanation
A client who expresses fear of experiencing pain near the end may be at risk for suicide. This statement suggests that the client is considering end-of-life issues, which may be a trigger for suicidal ideation. The other statements do not necessarily indicate a risk for suicide. Statement A suggests a desire for control, statement B expresses optimism, and statement C suggests reliance on a partner for support.
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