A nurse is assisting with triaging clients following an explosion. Which of the following clients should the nurse identify as the highest priority?
A conscious adult client who has second-degree burns on both lower legs; respiratory rate is > 30/min
A conscious adult client wearing a medic-alert diabetic bracelet, client reports feeling clammy and shaky.
An unconscious adult client who has a large head wound with gray matter exposed; absent respirations
An unconscious 6-month-old infant with no respirations, no visible injuries
The Correct Answer is A
A. In mass casualty triage, priority is given to clients who are salvageable with immediate intervention. This client is conscious (airway is intact) but has respiratory distress (RR > 30/min), suggesting potential inhalation injury or early shock. Prompt treatment can be life-saving.
B. This client is conscious but has symptoms potentially related to hypoglycemia rather than life-threatening injuries.
C. Unconscious adult with large head wound and exposed gray matter, absent respirations is unsalvageable; in triage terms, this client would be black tag (expectant). Immediate care will not change survival.
D. Unconscious 6-month-old infant with no respirations, no visible injuries is also considered unsalvageable without immediate resuscitation; triage prioritizes those with highest likelihood of survival.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A. Full body alopecia is a common side effect of chemotherapy but not directly related to myelosuppression.
B. Diarrhea and dehydration can occur with certain chemotherapeutic agents but are not specific to myelosuppression.
C. Anorexia and malnutrition are common during chemotherapy but are not specific to myelosuppression.
D. Myelosuppression can lead to decreased platelets and clotting factors, increasing the risk of bleeding from the gums and other sites.
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