A nurse is assisting with triaging clients in a mass casualty situation. The nurse should recommend that which of the following clients receive care first?
A client who has a head injury and whose pupils are fixed and dilated
A client who has a dislocated shoulder and reports a pain level of 8 on a scale from 0 to 10
A client who has a 20.3-cm (8-in) scalp laceration with intermittent bleeding
A client who has diminished breath sounds and paradoxical chest movement
The Correct Answer is D
The nurse should recommend that the client who has diminished breath sounds and paradoxical chest movement receive care first. This client is likely experiencing a tension pneumothorax, which is a life-threatening condition that requires immediate intervention.
Option a is incorrect because a client who has a head injury and whose pupils are fixed and dilated may have experienced brain death and may not be able to be resuscitated.
Option b is incorrect because a dislocated shoulder, while painful, is not immediately life-threatening. Option c is incorrect because a scalp laceration with intermittent bleeding can be managed with pressure and is not immediately life-threatening.
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Related Questions
Correct Answer is B
Explanation
To effectively communicate with a client who speaks a different language, it is important to use alternative methods of communication. One effective method is to supplement spoken language with pictures or visual aids. This can help bridge the language barrier and enhance understanding between the nurse and the client.
Recognize that the client nodding indicates an understanding of the information: Nodding does not always indicate understanding. It could be a cultural gesture or a sign of politeness. Relying solely on nodding may lead to miscommunication and misunderstanding.
Speak to the client at an increased volume: Speaking louder does not necessarily overcome the language barrier. It may make communication more difficult and could be perceived as rude or intimidating.
Ask a family member of the client to interpret: While involving a family member may seem helpful, it is not always reliable or appropriate. Family members may not be proficient in both languages or may not fully understand medical terminology. Additionally, the client may desire privacy or may not want to burden their family members with the responsibility of interpretation.
Correct Answer is A
Explanation
A respiratory rate of 8 breaths per minute with shallow respirations and cyanosis indicates severe respiratory distress or failure. In this situation, the client's oxygenation is compromised, and immediate intervention is needed to ensure an open and unobstructed airway. The nurse should prioritize ensuring the client has a patent airway by assessing for any airway obstruction and taking appropriate measures to clear the airway if necessary. This may involve techniques such as the head tilt-chin lift or jaw thrust maneuver.
While administering oxygen, checking the client's pulse rate, and placing a pulse oximeter on the client's finger are all important interventions in managing respiratory distress, the first and most critical step is to establish a patent airway. Without a clear airway, the client's oxygenation cannot be adequately addressed, and other interventions may be ineffective. Once the airway is secured, the nurse can proceed with providing oxygen, assessing the client's vital signs, and monitoring oxygen saturation using a pulse oximeter.
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