A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care?
A client who has severe head injuries, respiratory rate 6/min, and is unresponsive
A client who has a simple fracture of the femur, multiple scratches on both legs, and is crying hysterically
A female who is pregnant at 20 weeks of gestation, has multiple cuts and abrasions, and is walking around
A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site
The Correct Answer is D
Choice A Reason: This is incorrect because this client has signs of brain death, such as severe head injuries, low respiratory rate, and unresponsiveness. The nurse should tag this client as black, which means deceased or expectant.
Choice B Reason: This is incorrect because this client has non-life-threatening injuries, such as a simple fracture and scratches. The nurse should tag this client as green, which means minor or delayed care.
Choice C Reason: This is incorrect because this client has minor injuries and is able to walk around. The nurse should tag this client as green, which means minor or delayed care.
Choice D Reason: This is correct because this client has a life-threatening condition called tension pneumothorax, which requires immediate care. This client has a life-threatening condition called tension pneumothorax, which is caused by air leaking into the pleural space and compressing the lung and the heart. This can lead to respiratory failure, cardiac arrest, and death if not treated immediately. The hissing sound indicates that air is escaping from the lung through the wound. The nurse should tag this client as red, which means immediate care is needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice a) is correct because copies of insurance cards can help clients access medical care and claim compensation in case of a disaster. Insurance cards can also serve as a form of identification if other documents are lost or damaged.
Choice b) is correct because a whistle can help clients signal for help or locate each other in case of an emergency. A whistle can also deter potential atackers or wild animals.
Choice c) is incorrect because antibiotics are not recommended to be included in a disaster readiness supply kit or “go bag”. Antibiotics are prescription drugs that should only be used under the guidance of a health care provider. Using antibiotics without proper indication, dosage, or duration can cause adverse effects, such as allergic reactions, resistance, or superinfection.
Choice d) is correct because household bleach can be used to disinfect water, surfaces, or wounds in case of a disaster. Household bleach can also be used to create chlorine gas, which can be used as a weapon or a deterrent.
Choice e) is correct because pencil and paper can be used to write down important information, such as contact numbers, medical history, or evacuation plans. Pencil and paper can also be used to communicate with others, especially if there is no access to phone or internet services.
Correct Answer is D
Explanation
The correct answer is D. Blood pressure 115/68 mm Hg.
Choice A reason: Heart rate 180/min is incorrect because, although an increased heart rate is a compensatory mechanism, a rate of 180/min is excessively high and suggests a more severe stage of shock or other cardiac issues.
Choice B reason: Mottled skin is incorrect as it indicates poor perfusion seen in decompensated shock, where organ dysfunction begins to manifest, not in the compensatory stage.
Choice C reason: Hypokalemia, or low potassium levels, is incorrect because electrolyte imbalances are not typically a finding in the compensatory stage of shock. Normal potassium levels range from 3.5 to 5.0 mEq/L.
Choice D reason: Blood pressure 115/68 mm Hg is correct because it falls within the normal blood pressure range, which the body strives to maintain during the compensatory stage of shock through various mechanisms.
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