A nurse in the emergency department is triaging clients following a mass casualty event. The nurse should identify which of the following clients as emergent?
A client who reports flank pain radiating to the groin
A client who has multiple fractures
A client with partial thickness burns to both hands
A client who has a punctured femoral artery
The Correct Answer is D
A. A client who reports flank pain radiating to the groin: This could indicate renal colic or a kidney stone. While painful and concerning, it is not as immediately life-threatening as severe hemorrhage.
B. A client who has multiple fractures: Multiple fractures are serious but may not be as immediately life-threatening as severe hemorrhage or airway compromise.
C. A client with partial thickness burns to both hands: While painful and needing care, partial thickness burns are less critical compared to life-threatening hemorrhage.
D. A client who has a punctured femoral artery: This is an emergent situation because it involves severe hemorrhage. The femoral artery is a major artery, and puncture could lead to life-threatening blood loss and requires immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Increased sweating: This is incorrect. Increased sweating is not typically indicative of internal hemorrhaging. It can be associated with various conditions but is not a specific sign of internal bleeding.
B. Increased redness at the site: This is incorrect. Increased redness would more likely be associated with localized infection or inflammation rather than internal hemorrhaging.
C. Increased abdominal distention: This is correct. Increased abdominal distention can be a sign of internal hemorrhaging, particularly if blood accumulates in the abdominal cavity (hemoperitoneum), leading to abdominal swelling and discomfort.
D. Increased blood pressure: This is incorrect. Internal hemorrhaging often leads to hypotension rather than increased blood pressure, as blood volume decreases and the body attempts to compensate.
Correct Answer is C
Explanation
A. "It provides an area where clients can be provided a shower and privacy." This is incorrect. While decontamination areas may include showers for client decontamination, the primary rationale is more focused on preventing contamination rather than providing privacy.
B. "It provides a centralized area for the triage of all clients as they arrive to the facility." This is incorrect. Centralized triage is important but not the primary reason for a decontamination area.
C. "It prevents secondary contamination to the facility and its healthcare providers." This is correct. The primary rationale for a designated decontamination area is to prevent secondary contamination of the facility and its personnel by removing contaminants from individuals before they enter the healthcare environment.
D. "It serves as a holding area that isolates the clients who have been exposed to the agent." This is incorrect. Isolation may be a component, but the main purpose of decontamination is to prevent contamination spread.
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