A nurse is triaging clients following a mass casualty accident. Which of the following clients should be the nurse's priority?
A client who has an open fractured femur and reports severe pain
A client who has vomited twice and has contusions to both arms and shoulders
A client who has a metal bar protruding from the upper abdomen and is hyperventilating
A client who has several large lacerations to the upper extremities and can explain what occurred
The Correct Answer is C
A) A client who has an open fractured femur and reports severe pain:
An open fractured femur is a serious injury that requires attention due to the risk of infection and bleeding. However, it is not as immediately life-threatening as the complications associated with a protruding metal bar and hyperventilation. The severe pain, while significant, is secondary to addressing the most life-threatening conditions.
B) A client who has vomited twice and has contusions to both arms and shoulders:
While this client may be experiencing symptoms of potential internal injuries or trauma, vomiting and contusions alone do not indicate an immediate life-threatening situation compared to the other conditions. Further assessment is needed, but this client is not the priority in a mass casualty situation.
C) A client who has a metal bar protruding from the upper abdomen and is hyperventilating:
A metal bar protruding from the upper abdomen poses an immediate threat to vital organs, such as the liver, spleen, or intestines, and can cause severe internal bleeding or damage. Hyperventilation indicates possible hypoxia or shock. This client is the highest priority as they face the greatest immediate risk of life-threatening injury.
D) A client who has several large lacerations to the upper extremities and can explain what occurred:
Large lacerations need attention to prevent infection and control bleeding. However, the ability to explain the situation and the absence of immediate life-threatening signs suggest that this client’s condition is less critical compared to others with more severe or life-threatening injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) A client who has a headache following a grade 1 concussion:
A headache following a grade 1 concussion usually indicates a mild injury. Although the client may need monitoring, they are not typically at high risk for rapid deterioration that would necessitate proximity to the nurses' station.
B) A client who has a score of 0 on the NIH Stroke Scale following a transient ischemic attack:
A score of 0 on the NIH Stroke Scale indicates no symptoms of stroke. While close monitoring is important after a transient ischemic attack, this client’s condition is stable, and they might not need to be in the room closest to the nurses' station.
C) A client who has experienced brain death and is awaiting organ procurement:
A client who has experienced brain death is typically stable in terms of neurological status, although they may require monitoring for other reasons. However, their neurological condition would not require immediate proximity to the nurses' station compared to more acute conditions.
D) A client who has a score of 10 on the Glasgow Coma Scale following a motor vehicle crash:
A score of 10 on the Glasgow Coma Scale indicates moderate to severe impairment of consciousness, which suggests a higher risk of rapid deterioration. This client should be placed in the room closest to the nurses' station for continuous monitoring and immediate intervention if needed.
Correct Answer is B
Explanation
A) Store the CPM machine on the floor when not in use:
Storing the CPM machine on the floor can lead to contamination or damage. It should be stored in a clean, dry, and appropriate location when not in use to maintain its functionality and hygiene. Keeping it off the floor minimizes the risk of injury or contamination.
B) Turn the CPM machine off while the client is eating:
Turning off the CPM machine while the client is eating allows for comfort and safety during meals. It also prevents any potential interference with the client's ability to eat and reduces the risk of accidental injury or obstruction while using the machine.
C) Check settings of the CPM machine every 12 hr:
The settings of the CPM machine should be checked more frequently than every 12 hours to ensure that they are correctly adjusted according to the client's needs and rehabilitation goals. Regular monitoring is crucial to adjust settings and prevent complications.
D) Increase the range of motion rapidly when the CPM machine is used intermittently:
Rapidly increasing the range of motion can cause discomfort or harm to the client. Adjustments to the range of motion should be made gradually and according to the client's tolerance and rehabilitation plan to avoid complications and promote safe healing.
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