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 B
Explanation
A school nurse caring for a child with muscular dystrophy who is having difficulty swallowing at lunch should initiate a referral to a speech-language therapist. Swallowing difficulties, or dysphagia, can lead to aspiration and respiratory complications. Speech-language therapists specialize in the evaluation and treatment of dysphagia. Occupational therapists may also work with clients who have dysphagia to help with positioning and adaptive equipment, but their primary focus is on activities of daily living. Dietitians may be consulted for nutritional support, but they are not trained to evaluate or treat dysphagia. Respiratory therapists may be involved in the care of clients with dysphagia who have respiratory complications, but they are not the primary referral for this issue.
Correct Answer is A
Explanation
Parenting classes are a primary prevention strategy to decrease community violence. These classes provide parents with the necessary knowledge and skills to prevent violence and promote healthy child development. Developing a protocol for managing victims of violence is a secondary prevention strategy because it aims to minimize the harm caused by violence. Arranging for a local clinic to provide methadone treatment and providing sexual assault nurse examiner training for nurses in the local clinic are tertiary prevention strategies because they aim to prevent further harm and improve the quality of life for those who have experienced violence.
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