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A nurse is triaging a group of clients as they arrive simultaneously in the emergency department following a nearby bus crash

Which of the following clients should the nurse transfer to the three available trauma rooms? Select the 3 clients to transfer for immediate treatment.

Client 1

Client 2

Client 3

Client 4

Client 5

Client 6

Answer and Explanation

Correct Answer : A,D,F

Rationale:

Client 1: The client has a large laceration (10.2 cm) with radial pulses 2+, tachycardia (HR 114/min), and pain 6/10. While the blood pressure is slightly elevated, the client requires immediate trauma care for bleeding control and pain management, making them a priority for a trauma room.
Client 2: This client has bruising and abrasions with stable vital signs and no signs of life-threatening injuries. They can wait for care in a less acute area, so immediate trauma room transfer is not required.
Client 3: The client has minor contusion and nausea, is alert and oriented, and vital signs are stable. This is a lower priority patient, so trauma room transfer is not immediately necessary.
Client 4: The client has a cervical collar in place, absent lower extremity movement, GCS 14, and borderline hypotension. These findings indicate spinal injury and potential neurogenic shock, making the client high priority for immediate trauma care.
Client 5: The client has closed head injury, traumatic amputation, CPR in progress, asystole, fixed pupils, and agonal respirations. This patient is unsalvageable in the current scenario (expectant in mass-casualty triage) and would not occupy a trauma room immediately.
Client 6: The client has hypotension (BP 82/54 mm Hg), tachycardia (HR 124/min), abdominal bruising, and is ambulatory but at risk for internal bleeding or shock, requiring immediate trauma room transfer.

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Correct Answer is A

Explanation

Rationale:

A. Scheduling the consultation when the primary nurse can attend ensures effective communication between the care team and the wound care specialist. The nurse can provide accurate, up-to-date information about the client’s condition, treatments, and response to care, which supports continuity and quality of care.

B. Arranging for daily visits by the wound care specialist is not necessary in most cases and could be resource-intensive. Frequency of consultation should be based on the client’s clinical needs rather than a fixed schedule.

C. Providing subjective opinions or beliefs is inappropriate. Consultants require objective, factual information about the client’s condition, such as wound measurements, appearance, and treatment response, to make informed recommendations.

D. Delaying the consultation until after several treatments are tried can risk worsening the pressure injury. Early involvement of a wound care specialist is recommended to promote healing, prevent complications, and optimize outcomes.

A. An adolescent client who has an injured ankle and reports a pain level of 8 on a scale from 0 to 10 B. An older adult client who has dyspnea and a respiratory rate of 26/min C. A toddler who has a 2 cm (0.79 in) head laceration oozing dark red blood D. An adult client who has large ecchymoses on both legs

Correct Answer is B

Explanation

Rationale:
A. An injured ankle with severe pain is important to assess for fractures or soft tissue injury, but it is not immediately life-threatening. This client can safely wait after more urgent cases are addressed.

B. An older adult with dyspnea and a respiratory rate of 26/min is showing signs of respiratory compromise. Airway and breathing problems are life-threatening and take priority according to the ABC (Airway, Breathing, Circulation) framework. Prompt assessment and intervention are required to prevent deterioration.

C. A toddler with a small head laceration that is oozing dark red blood requires attention, but the amount of bleeding described is not severe enough to be immediately life-threatening. The wound can be treated after more urgent respiratory concerns are addressed.

D. An adult with large ecchymoses on both legs may have a bleeding or clotting disorder, but without signs of active bleeding, airway compromise, or hemodynamic instability, this is less urgent than respiratory distress.

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A nurse is triaging a group of clients as they arrive simultaneously in the emergency department following a nearby bus crash Which of the following clients should the nurse transfer to the three available trauma rooms? Select the 3 clients to transfer for immediate treatment.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is coordinating a consult with a wound care specialist for a client who has a pressure injury. Which of the following actions should the charge nurse take?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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A nurse is triaging a group of clients as they arrive simultaneously in the emergency department following a nearby bus crash

Which of the following clients should the nurse transfer to the three available trauma rooms? Select the 3 clients to transfer for immediate treatment.