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 B
Explanation
The correct answer is choice B. When caring for clients from different cultural backgrounds, it is important to be respectful and non-judgmental. In this situation, the nurse should ask the family to describe how they hope the treatments will affect their health. This will allow the nurse to gain a better understanding of the family's beliefs and values regarding health and illness. The nurse should avoid making assumptions or judgments about the family's beliefs and should not criticize or dismiss the folk healer. Alternative medicine practices (choice A) can be dangerous in some cases, but it is not appropriate to make a blanket statement that they should be avoided. Suggesting that folk medicine works by providing a placebo effect (choice C) is not respectful of the family's beliefs and is dismissive of their cultural practices. Referring the family to a medical practitioner (choice D) may not be appropriate if the family has a strong belief in folk medicine practices.
Correct Answer is C
Explanation
. Home safety measures are a priority for a client with alcohol use disorder and cirrhosis of the liver, as they may have mobility or balance issues that increase their risk of falls or injury. Assessing the client's home environment and identifying any potential hazards is crucial in preventing further injury or harm to the client. Once the home safety measures have been determined, the case manager can then arrange for a home health nurse to visit the client, provide information on self-help groups for alcohol use disorder, and contact a social worker to assist with managing finances.
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