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 C

Explanation

A. A client who has chronic obstructive pulmonary disease and needs guidance on incentive spirometry: Teaching and guiding a client on incentive spirometry is a nursing intervention that requires assessment, education, and evaluation. It cannot be delegated to assistive personnel.

B. A client who had a myocardial infarction 3 days ago and reports chest discomfort: Chest discomfort in a post-MI client is a high-priority, potentially life-threatening issue. Only a licensed nurse can assess, intervene, and notify the provider, so this task is not appropriate for delegation.

C. A client who had a stroke 2 days ago and needs help toileting: Assisting a client with toileting is a basic activity of daily living and falls within the scope of practice for assistive personnel. The nurse can delegate this task safely.

D. A client who has awoken following a bronchoscopy and requests a drink: Post-procedure assessment and evaluating readiness for oral intake requires nursing judgment to ensure airway safety. This cannot be delegated to assistive personnel.

A. Hypotension B. Tachycardia C. Muscle cramps D. Hyperreflexia

Correct Answer is A

Explanation

A. Hypotension: Elevated magnesium levels cause smooth muscle relaxation and vasodilation, which can lead to hypotension. Severe hypermagnesemia can depress cardiovascular function, making low blood pressure a key expected finding.

B. Tachycardia: Hypermagnesemia typically causes bradycardia rather than tachycardia due to its depressant effect on cardiac conduction. Tachycardia is more often associated with hypovolemia, pain, or sympathetic stimulation, not high magnesium levels.

C. Muscle cramps: Muscle cramps and tetany are more commonly associated with hypomagnesemia. High magnesium levels have a neuromuscular depressant effect, leading to weakness rather than cramping.

D. Hyperreflexia: Hyperreflexia occurs with low magnesium levels. In hypermagnesemia, deep tendon reflexes are diminished or absent due to the depressant effect on neuromuscular transmission.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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