A nurse is performing triage for a group of clients following a mass casualty incident (MCI). Which of the following clients should the nurse plan to care for first?
A client who has an open upper extremity fracture
A client experiencing a tension pneumothorax
A client who has full-thickness burns over 85% of their body
A client who has agonal respirations
The Correct Answer is B
A. A client who has an open upper extremity fracture: While this is a serious injury, it is less critical compared to a tension pneumothorax in a triage setting.
B. A client experiencing a tension pneumothorax: This is a life-threatening condition that requires immediate intervention to relieve pressure on the lungs and restore adequate breathing.
C. A client who has full-thickness burns over 85% of their body: This is a severe condition with a high mortality risk, but in a mass casualty situation, a tension pneumothorax is prioritized for immediate care.
D. A client who has agonal respirations: Agonal respirations indicate severe distress, but the immediate need for intervention is to address conditions that can rapidly compromise life, such as a tension pneumothorax.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Instruct the client to change clothing before arriving: This is incorrect. The client should keep the clothing worn during the assault as it may contain crucial evidence.
B. Inform the client that photographs of any injuries will be mandatory for a police report: This is incorrect. While evidence collection is important, it should be done with the client’s consent and consideration of their emotional state.
C. Ask the client to repeat the information obtained during admission: This is incorrect. Asking the client to repeat information can be traumatic. The history should be obtained sensitively and only as needed.
D. Obtain a history of the incident from the client: This is correct. The nurse needs to gather information to provide appropriate care and ensure evidence is collected properly. This should be done in a supportive and respectful manner.
Correct Answer is C
Explanation
A. A 28-year-old client who has a history of pelvic inflammatory disease: This is incorrect. While a history of pelvic inflammatory disease does not necessarily contraindicate oral contraceptive use, it should be assessed for any other potential complications or contraindications.
B. A 26-year-old client who is mobile post appendectomy: This is incorrect. Recent surgery, such as an appendectomy, is not a contraindication for oral contraceptives, provided the client is otherwise healthy.
C. A 38-year-old client who reports smoking one pack of cigarettes every day: This is correct. Smoking, especially in women over 35, is a contraindication for oral contraceptives due to the increased risk of cardiovascular events such as thrombosis.
D. A 32-year-old client who has fibrocystic breast disease: This is incorrect. Fibrocystic breast disease does not contraindicate the use of oral contraceptives.
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