Following an earthquake, patients are triaged by emergency medical personnel and transported to the emergency department (ED). Which patient will the nurse need to assess first?

A patient with a blue tag

A patient with a black tag

A patient with a yellow tag

A patient with a red tag

Answer and Explanation

The Correct Answer is D

A. A patient with a blue tag indicates minor injuries or illness and can wait for treatment.
B. A patient with a black tag is typically deceased or expected to die and is not a priority for immediate assessment.
C. A patient with a yellow tag indicates delayed treatment needs and can wait while more urgent cases are addressed.
D. A patient with a red tag indicates critical and life-threatening injuries requiring immediate assessment and intervention.

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Correct Answer is []

Explanation

Potential Condition:

Hypovolemia: The client shows signs of hypovolemia such as a low blood pressure (94/56 mm Hg), a high heart rate (110/min), and a relatively high urine output (1500 mL in the last hour), which may indicate an over-diuresis or inadequate fluid replacement postoperatively.

Actions to Take:

Obtain prescription for IV bolus: Administering an IV fluid bolus can help restore intravascular volume, thereby increasing blood pressure and improving perfusion to vital organs.

Lower head of bed: This action helps to increase venous return to the heart, which can help improve cardiac output and blood pressure in a hypovolemic patient.

Parameters to Monitor:

Urinary output: This is a key indicator of kidney function and fluid status. Monitoring urine output will help determine if the client is adequately responding to fluid resuscitation and maintaining appropriate kidney function.

Blood pressure: Continuous blood pressure monitoring is essential to evaluate the effectiveness of interventions aimed at correcting hypovolemia and ensuring the client's hemodynamic stability.

A. A client who has a simple fracture of the femur, multiple scratches on both legs, and is crying hysterically B. A client who has severe head injuries, respiratory rate 6/min, and is unresponsive C. A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site D. A female who is pregnant at 20 weeks of gestation, has multiple cuts and abrasions, and is walking around

Correct Answer is C

Explanation

A. While painful, a simple fracture and scratches do not pose an immediate threat to life compared to other injuries.
B. The client with severe head injuries and a low respiratory rate may seem like a priority, but if they are unresponsive and have a respiratory rate as low as 6/min, they may be beyond help.
C. A punctured chest with an audible hissing sound indicates a potential tension pneumothorax, a life-threatening condition that requires immediate intervention to prevent collapse of the lung and other potentially fatal complications.
D. A pregnant woman with cuts and abrasions should be evaluated promptly but is not as critical as clients with severe head injuries or tension pneumothorax.

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Following an earthquake, patients are triaged by emergency medical personnel and transported to the emergency department (ED). Which patient will the nurse need to assess first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

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Correct Answer is C

Explanation

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