A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first?
A client who has a small circular partial-thickness burn of the left calf.
A client who has severe respiratory stridor and a deviated trachea.
A client who has a splinted open fracture of the left medial malleolus.
A client who has a massive head injury and is experiencing seizures.
The Correct Answer is B
Choice A reason: A Client Who Has a Small Circular Partial-Thickness Burn of the Left Calf
A small circular partial-thickness burn of the left calf is considered a minor injury in the context of a mass casualty event. This type of injury does not pose an immediate threat to life and can be managed after more critical cases are addressed. In mass casualty triage, patients with minor injuries are often categorized as “green” or “minimal” and are treated last.
Choice B reason: A Client Who Has Severe Respiratory Stridor and a Deviated Trachea
A client with severe respiratory stridor and a deviated trachea should be assessed first. These symptoms indicate a potential airway obstruction, which is a life-threatening condition requiring immediate intervention. In mass casualty triage, patients with compromised airways are given the highest priority and are categorized as “red” or “immediate” because their condition is critical and requires urgent medical attention.
Choice C reason: A Client Who Has a Splinted Open Fracture of the Left Medial Malleolus
A splinted open fracture of the left medial malleolus is a serious injury but not immediately life-threatening if properly splinted. This client would be categorized as “yellow” or “delayed” in mass casualty triage, meaning they require medical attention but can wait until more critical patients are stabilized.
Choice D reason: A Client Who Has a Massive Head Injury and Is Experiencing Seizures
A client with a massive head injury and experiencing seizures is in a critical condition. However, in the context of mass casualty triage, the immediate priority is to secure the airway, breathing, and circulation. While this client is in dire need of medical attention, the presence of severe respiratory stridor and a deviated trachea in another client takes precedence due to the immediate threat to life.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
The first step in removing an NG tube is to verify the provider’s prescription to discontinue the tube. This ensures that the removal is authorized and appropriate for the client’s current condition.
Choice B reason:
Disconnecting the tube from the wall suction is an important step, but it should be done after verifying the provider’s prescription. This step prevents any suction-related complications during the removal process.
Choice C reason:
Performing hand hygiene is crucial to prevent infection, but it is not the first step. Hand hygiene should be performed after verifying the provider’s prescription and before touching the client or any equipment.
Choice D reason:
Providing mouth care to the client is important for comfort and hygiene, but it is not the first step in the process of removing an NG tube. This can be done after the tube has been safely removed.
Correct Answer is C
Explanation
Choice A reason: Dried fruits
Dried fruits are generally high in fiber, which can be problematic for individuals with a colostomy, especially in the initial weeks following surgery. High-fiber foods can increase stool bulk and may cause blockages or discomfort. It is recommended to avoid high-fiber foods until the digestive system has adjusted and the healthcare provider gives the go-ahead to reintroduce them gradually.
Choice B reason: Dried peas
Dried peas, like other legumes, are also high in fiber and can cause gas and bloating. These symptoms can be particularly uncomfortable for individuals with a colostomy. Additionally, legumes can increase the risk of blockages in the stoma. Therefore, it is advisable to avoid dried peas and other high-fiber legumes until the digestive system has fully adjusted.
Choice C reason: Eggs
Eggs are an excellent food choice for individuals with a colostomy. They are high in protein, which is essential for wound healing and overall recovery. Eggs are also easy to digest and do not typically cause gas or bloating. Including eggs in the diet can help ensure that the client receives adequate nutrition without causing digestive discomfort.
Choice D reason: Pasta
Pasta, particularly refined pasta, is generally low in fiber and easy to digest, making it a suitable food choice for individuals with a colostomy. It provides a good source of carbohydrates, which are important for energy. However, it is essential to monitor portion sizes and avoid adding high-fat or high-fiber ingredients that could cause digestive issues.
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