Following an explosion at a local chemical lab, several people have sustained burns and are now in the triage area.
Which patient should be attended to first?
A 33-year-old with burns to the back and shoulders.
A 32-year-old with burns on the hands and face.
A 42-year-old with burns on both legs.
A 25-year-old with a burn on the left arm.
The Correct Answer is B
Choice A rationale
A 33-year-old with burns to the back and shoulders. While this patient’s injuries are serious, they are not immediately life-threatening. The back and shoulders are not vital areas, and while pain management and wound care will be necessary, this patient’s situation is not as urgent as others.
Choice B rationale
A 32-year-old with burns on the hands and face. This patient should be attended to first. Burns on the hands and face are more serious due to the high risk of infection and the potential for complications such as impaired breathing if the airway swells or becomes blocked due to the burns. Immediate treatment can help to prevent these complications.
Choice C rationale
A 42-year-old with burns on both legs. While these burns are serious, they are not immediately life-threatening. The patient will need pain management and wound care, and may have mobility issues, but their vital organs are not directly impacted by the burns.
Choice D rationale
A 25-year-old with a burn on the left arm. This patient, while in need of treatment, is not the highest priority. A burn on the arm, while painful and requiring treatment, is not as potentially serious or life-threatening as burns to the face, hands, or major portions of the body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Holding tube feeding 1 hour before and 2 hours after to avoid clumping is not a specific nursing intervention when administering Dilantin (phenytoin)1011.
Choice B rationale
Monitoring the patient for lethargy and drowsiness is important as these may indicate a high drug level of Dilantin (phenytoin), which can lead to toxicity.
Choice C rationale
Informing the patient that they may experience increased and large amounts of urinary output is not a specific nursing intervention when administering Dilantin (phenytoin)1011.
Choice D rationale
Advising the patient to use an extra soft toothbrush to avoid gum bleeding is a general recommendation for patients on anticoagulant therapy, not specifically for those taking Dilantin (phenytoin)1011.
Correct Answer is C
Explanation
Choice A rationale
The femoral pulse is located in the groin area and is often used during procedures or when other pulse sites are not available. It does not directly assess circulation to the brain.
Choice B rationale
The radial pulse, located on the thumb side of the wrist, is commonly used to measure heart rate but does not directly assess circulation to the brain.
Choice C rationale
The carotid pulse is located on either side of the neck below the jawline. It is one of the major arteries that supply blood to the brain. In an emergency, this pulse site is used to assess circulation to the brain.
Choice D rationale
The popliteal pulse is located behind the knee and is used to assess circulation to the lower leg. It does not directly assess circulation to the brain.
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