The emergency department triage nurse receives notification there has been a mass shooting incident at a local shopping mall with several casualties injured. The hospital’s emergency response plan is initiated. Which client should the nurse prioritize for care?
Client with a sucking chest wound, conscious, blood pressure 88/58 mm Hg, heart rate 115/min, and red tag observed.
Client with a significant penetrating head wound, unconscious with irregular breathing pattern, and black tag observed.
Client with superficial lacerations to the left arm and left lower leg.
Client with closed left lower leg injury, air cast in place, pain reported as 9 on a 0 to 10 numeric pain scale.
The Correct Answer is A
Choice A rationale
A sucking chest wound compromises breathing, causes tension pneumothorax, and decreases cardiac output. Hypotension (88/58 mm Hg) and tachycardia (115/min) indicate shock, warranting immediate intervention. Red tag signifies life-threatening but potentially survivable injuries.
Choice B rationale
Penetrating head wounds with irregular breathing suggest brainstem injury, poor prognosis, and impending death. Black tag indicates un-survivable injuries, prioritizing resource allocation to others with a better survival potential.
Choice C rationale
Superficial lacerations involve minor soft tissue damage that does not compromise vital functions. These injuries are non-life-threatening and can wait for delayed medical care without significant risk to life or function.
Choice D rationale
Closed lower leg injuries cause localized pain but do not compromise airway, breathing, or circulation. Pain severity does not indicate life-threatening harm, allowing delayed care. Yellow tag signifies urgent but not immediate need for treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Hand gestures enhance nonverbal communication by providing visual cues, essential for clients with hearing loss. Limiting gestures reduces communication effectiveness, increasing reliance on verbal cues, which are less accessible for these clients.
Choice B rationale
Increased volume may distort sound clarity and cause discomfort without improving comprehension for individuals with hearing loss. Consistent tone, pace, and clear articulation are more effective in supporting understanding for these clients.
Choice C rationale
Written materials aid visual learning and reinforce understanding by providing a reliable communication method for individuals with hearing loss. This compensates for auditory deficits and ensures clear and accurate information exchange.
Choice D rationale
Limiting visitors doesn't address the root issue of effective communication. Proper techniques like visual aids or written communication are essential to overcome auditory barriers in clients with hearing loss.
Correct Answer is A
Explanation
Choice A rationale
Nausea is a direct clinical manifestation of enteral feeding intolerance, often resulting from delayed gastric emptying or improper feeding rate, leading to gastrointestinal distress and potential aspiration risks.
Choice B rationale
A urine output of 40 mL/hr, while indicative of oliguria and potential renal compromise, is not associated with gastrointestinal intolerance to enteral feedings, as these involve different organ systems.
Choice C rationale
Soft stools are not a reliable indicator of feeding intolerance. They can occur due to dietary composition changes but are not associated with pathologic conditions needing intervention.
Choice D rationale
Headache is a nonspecific symptom that does not relate directly to feeding intolerance. Other causes, such as dehydration or systemic factors, are more likely culprits for this presentation.
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