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","D","E"]
Explanation
The correct answer is choices C, D, and E. Hospice care is a type of healthcare that focuses on improving the quality of life for individuals who have a terminal illness. Patients who receive hospice care have the option to discontinue this service whenever they want. Hospice care can be provided at home, hospital, or any other place that the patient calls home. In addition, hospice care involves a team of interprofessional team members, such as nurses, social workers, chaplains, and counselors, who provide care to the patient and their family. Hospice care is covered by Medicare, and the patient doesn't need private insurance to receive hospice services. Patients are recommended for hospice care when they have a life expectancy of 6 months or less.
Correct Answer is B
Explanation
Cultural variances in the expression of pain can impact the assessment and management of pain. It is important to recognize and respect these cultural differences to provide culturally sensitive care. Puerto Rican cultural practices consider the expression of pain as a private matter, and individuals may not express their pain openly, as it may be viewed as a weakness or shameful. In contrast, Native American cultural practices often consider pain as a sign of strength, and individuals may express pain openly to receive validation and support from their community. Chinese cultural practices emphasize the importance of stoicism, and individuals may endure pain to prevent family dishonor. Middle Eastern cultural practices may consider pain as a test of faith, and individuals may hide their pain from close family members to avoid burdening them. By understanding these cultural variances, nurses can assess pain more effectively and develop culturally sensitive pain management plans.
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