A nurse is the triage officer in the emergency department during a disaster when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?
An unconscious adult client who has no respirations, capillary refill is > 2 seconds, and paramedics have already tried to reposition airway without results
A conscious adult client who has a broken tibia, blood pressure of 160/90 mm Hg, and heart rate of 118 beats per minute
An unconscious adult client who has a sucking chest wound, SpO2 of 85%, and capillary refill of < 2 seconds
A conscious adult client who reports shortness of breath, has a respiratory rate of 24/min, and capillary refill of <2 seconds
The Correct Answer is C
C. The unconscious adult client with a sucking chest wound and low SpO2 (85%) is in immediate need of intervention. A sucking chest wound is a life-threatening injury that can lead to respiratory distress and compromised oxygenation. This client requires immediate attention to address the chest wound and improve oxygenation.
A. The unconscious client with no respirations and an ineffective airway attempt is likely beyond rescue, making them lower priority compared to those with potentially reversible conditions.
B. The conscious client with a broken tibia and elevated vital signs is stable enough to be seen after more critical cases are addressed.
D. The conscious client with shortness of breath and a high respiratory rate is concerning but not as immediately life-threatening as a client with a sucking chest wound.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"E"}
Explanation
Pneumonia: The client is at risk for pneumonia due to decreased lung expansion and increased risk of aspiration, especially after abdominal surgery.
Deep vein thrombosis (DVT): The client is at risk for DVT due to prolonged immobility and the increased risk of blood clots associated with surgery.
Urinary retention: The Foley catheter may interfere with the client's ability to void normally, increasing the risk of urinary retention.
Correct Answer is A
Explanation
A. Hypovolemic shock is characterized by low blood pressure, pale skin, and abdominal pain due to significant fluid loss or hemorrhage. The client's symptoms, including hypotension and abdominal pain, suggest a reduction in blood volume potentially caused by gastrointestinal bleeding or ulceration, which is consistent with chronic aspirin use.
B. Obstructive shock is due to a physical obstruction of blood flow, such as a pulmonary embolism or cardiac tamponade, which does not directly correlate with the client's presentation of symptoms.
C. Cardiogenic shock results from severe heart failure and is typically accompanied by signs of heart dysfunction, not just low blood pressure and abdominal pain.
D. Septic shock is associated with infection and systemic inflammation, often presenting with fever and other signs of infection, which the client is not exhibiting.
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