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.

Answer and Explanation

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.

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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.

A. Blurred vision B. Severe headache C. Oriented to person, place, and year D. Bradycardia

Correct Answer is B

Explanation

Choice A reason:

Blurred vision: While blurred vision can occur in some cases of meningitis, it is not one of the most common or definitive symptoms. Meningitis primarily affects the meninges, leading to symptoms like headache, fever, and neck stiffness. Blurred vision might be a secondary symptom due to increased intracranial pressure, but it is not as typical as other symptoms.

Choice B reason:

Severe headache: A severe headache is a hallmark symptom of meningitis. This headache is often described as intense and different from typical headaches. It is caused by the inflammation of the meninges, which are the protective membranes covering the brain and spinal cord. The headache is usually accompanied by other symptoms such as fever, neck stiffness, and sensitivity to light.

Choice C reason:

Oriented to person, place, and year: Being oriented to person, place, and year indicates normal cognitive function. However, meningitis can cause confusion, altered mental status, and even loss of consciousness in severe cases. Therefore, this finding would not be expected in a client with meningitis.

Choice D reason:

Bradycardia: Bradycardia, or a slow heart rate, is not typically associated with meningitis. Meningitis symptoms are more related to the central nervous system and include fever, headache, neck stiffness, and altered mental status. Bradycardia might occur in other conditions but is not a common finding in meningitis.

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A nurse is triaging clients following a mass casualty event. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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