A nurse is triaging clients who were involved in a commuter train crash. Which of the following clients should the nurse choose for transport to the emergency department first?
A client who has a fracture of the humerus with a 2+ radial pulse in the affected arm
A client who has full-thickness burn injuries over 30% of his total body surface area
A client who is exhibiting agonal respirations with fixed and dilated pupils
An ambulatory client who has a nosebleed and reports feeling dizzy
The Correct Answer is B
In a mass casualty incident (MCI) like a train crash, triage is based on the severity of injuries and likelihood of survival using the START (Simple Triage and Rapid Treatment) system. Clients are categorized as Immediate (Red), Delayed (Yellow), Minor (Green), or Expectant (Black).
A. A client with a humerus fracture and a 2+ radial pulse (Yellow - Delayed): The client is stable and not the highest priority for immediate transport.
B. A client with full-thickness burns over 30% TBSA (Red - Immediate): This client has life-threatening injuries requiring urgent treatment for airway support, fluid resuscitation, and burn care.
C. A client with agonal respirations and fixed, dilated pupils (Black - Expectant): This client is unlikely to survive even with treatment, so in an MCI, resources should be allocated to those with a higher chance of survival.
D. An ambulatory client with a nosebleed and dizziness (Green - Minor): This client is walking wounded and can wait for medical care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Explanation: Heroin is a central nervous system depressant that can cause various physiological effects on the body. Dilated pupils are a common sign of heroin use, along with a decrease in blood pressure, respiratory rate, and heart rate. The pupils will appear larger than usual because heroin depresses the parasympathetic nervous system, which controls the size of the pupils.
Tachypnea, or rapid breathing, is not typically associated with heroin use, as it is a central nervous system depressant. Euphoria, or a feeling of intense pleasure or happiness, is a common effect of heroin use, but it is not the most reliable sign of heroin use, as other drugs can also produce this effect. Nystagmus, an involuntary movement of the eyes, is not a common sign of heroin use. Dilated pupils are a reliable sign of heroin use and should be documented in the client's medical record. It is important for the nurse to assess for other signs of drug use and to provide appropriate care and support to the client, which may include referrals for substance abuse treatment. The nurse should also follow agency policies and procedures for reporting drug use and abuse to appropriate authorities.
Correct Answer is B
Explanation
B. Interviewing shelter residents to determine the effectiveness of coping behaviors:This is a secondary prevention strategy as it focuses on early identification of stress-related conditions or mental health concerns in disaster survivors. By assessing coping behaviors, the nurse can detect maladaptive responses and intervene early to prevent further mental or physical health complications.
Incorrect:
A. Compiling resources available to transition individuals from shelters to a home:This is a tertiary prevention strategy because it focuses on helping individuals recover and rebuild their lives post-disaster.
C. Publishing a listing of shelter locations in local media sources:
This is a primary prevention strategy as it involves preparedness and prevention. Providing information about shelter locations can help individuals seek immediate refuge during a disaster, reducing exposure to harm.
D. Providing age-appropriate activities for shelter residents:This intervention aligns with tertiary prevention, as it aims to promote emotional recovery and well-being for individuals who have already experienced a disaster. Age-appropriate activities help reduce stress and enhance coping for shelter residents.
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