A nurse is performing triage following a natural disaster. Which of the following clients should the nurse identify as the highest priority to receive care?

A client who has agonal respirations

A client who has an open skull fracture and is unresponsive

A client who has a traumatic arm amputation

A client who has a fracture of the femur

Answer and Explanation

The Correct Answer is C

A. A client who has agonal respirations: Agonal respirations indicate imminent death and the likelihood of non-survivability. In a disaster triage situation, resources are prioritized for clients with the highest chance of survival, so this client would not be the immediate priority.

B. A client who has an open skull fracture and is unresponsive: This client has severe head trauma and a poor prognosis. While critical, disaster triage focuses on saving the most lives, so clients with non-survivable injuries are not prioritized over those who can benefit from immediate intervention.

C. A client who has a traumatic arm amputation: This client has a life-threatening injury that is potentially survivable with rapid intervention, such as hemorrhage control. In disaster triage, clients with critical but treatable injuries are prioritized first to maximize survival outcomes.

D. A client who has a fracture of the femur: Although a femur fracture is serious and requires care, it is generally not immediately life-threatening. This client can be treated after those with urgent, life-saving needs like hemorrhage control.

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Correct Answer is D

Explanation

A. Confirm schedule for delivery of supplies: Ensuring supplies are delivered is important for continuity of care, but it does not address the client’s immediate needs or understanding of peritoneal dialysis. This can be arranged after assessing needs.

B. Coordinate interdisciplinary health care services: Collaboration with other healthcare providers is essential for comprehensive care, but initiating coordination should follow a thorough assessment of the client’s specific needs and goals.

C. Demonstrate how to perform the procedure: Teaching the procedure is a critical step, but effective teaching requires understanding the client’s current knowledge, abilities, and perceived needs first. Without this assessment, instruction may not be individualized or effective.

D. Clarify the client’s actual and perceived health needs: Assessing both objective and perceived needs establishes a foundation for individualized care planning, teaching, and coordination. This is the first action because it informs all subsequent interventions and ensures the client’s priorities are addressed.

A. Jugular vein distention B. Weight gain C. Peripheral edema D. Bilateral lung crackles

Correct Answer is D

Explanation

A. Jugular vein distention: Jugular vein distention is more indicative of right-sided heart failure due to increased venous pressure. While important to note, it is not a primary sign of left-sided heart failure.

B. Weight gain: Weight gain can occur in both right- and left-sided heart failure due to fluid retention. However, it is a nonspecific finding and does not localize the dysfunction to the left side of the heart.

C. Peripheral edema: Peripheral edema is commonly associated with right-sided heart failure, where fluid backs up into the extremities. It is not the earliest or most specific sign of left-sided heart failure.

D. Bilateral lung crackles: Crackles on auscultation of the lungs indicate pulmonary congestion or fluid accumulation, a hallmark of left-sided heart failure. This finding reflects impaired left ventricular function and should be reported promptly to the provider for evaluation and management.

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A nurse is performing triage following a natural disaster. Which of the following clients should the nurse identify as the highest priority to receive care?

Nursing Test Bank

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