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A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?

A conscious adult client who reports shortness of breath, has a respiratory rate of 24/min, and capillary refill of <2 seconds

A conscious adult client who has a dislocated right shoulder, respiratory rate of 18/min, and capillary refill of <2 seconds

An unconscious adult client who has a sucking chest wound, respirations of 38/min, and capillary refill of <2 seconds

An unconscious adult client who has no respirations, capillary refill is 2 seconds and paramedics have already tried to reposition airway without results

Answer and Explanation

The Correct Answer is C

A. This client has respiratory distress but is conscious and stable, requiring urgent but not immediate attention compared to other critical conditions.
B. This client has a dislocated shoulder, which is painful and needs attention but is not life-threatening compared to other conditions.
C. This client is unconscious with a sucking chest wound and high respiratory rate, indicating severe respiratory compromise and needing immediate intervention to prevent further deterioration.
D. This client is also unconscious with no respirations despite attempted airway management, indicating a need for immediate resuscitative efforts, potentially including CPR.

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Correct Answer is C

Explanation

A. Sending blood to the lab for a complete blood count can wait until after immediate stabilization measures are initiated.
B. Finishing the primary survey is important, but the absent pulses and swollen leg suggest a critical vascular issue that needs immediate attention.
C. Assessing further for the cause of decreased circulation is the next step to determine if immediate intervention such as surgical consultation or revascularization is needed.
D. Starting normal saline infusion may be necessary later, but determining the cause of decreased circulation takes priority to prevent potential limb loss.

Correct Answer is ["200"]

Explanation

To calculate the infusion rate in mL/hr for administering ceftriaxone 1 g via intermittent IV bolus over 30 minutes, you would use the formula: (Total Volume in mL / Time in hours) = Rate in mL/hr. In this case, the total volume of the solution is 100 mL, and the time frame is 0.5 hours (since 30 minutes is half an hour). Therefore, the calculation would be 100 mL / 0.5 hours = 200 mL/hr.

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A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?

Correct Answer is C

Explanation

Correct Answer is ["200"]

Explanation

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