An emergency room nurse is triaging victims of a mass-casualty event. Which client should receive care first?

A 30-year-old distraught mother holding her crying child

A 65-year-old conscious male with a head laceration

A 48-year-old with a simple fracture of the lower leg

A 26-year-old male who has pale, cool, clammy skin

Answer and Explanation

The Correct Answer is D

A. A 30-year-old distraught mother holding her crying child: While the mother is distraught, her condition does not appear life-threatening. This client should be triaged to a lower priority compared to those with immediate medical needs.

B. A 65-year-old conscious male with a head laceration: A head laceration in a conscious client is concerning but not immediately life-threatening unless there are signs of more serious brain injury (e.g increased intracranial pressure). This client would be triaged as urgent, not emergent.

C. A 48-year-old with a simple fracture of the lower leg: A simple fracture is painful but does not typically threaten life or limb. This client is categorized as urgent but not emergent compared to others with more critical needs.

D. A 26-year-old male who has pale, cool, clammy skin: This client is showing signs of shock, which is a medical emergency. Pale, cool, and clammy skin suggests hypoperfusion, potentially due to hemorrhage, dehydration, or trauma. This client requires immediate intervention to restore circulation and prevent further deterioration.

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Correct Answer is C

Explanation

A. "PEEP will prevent lung damage while the patient is on the ventilator.": While PEEP helps keep the lungs inflated, it is not specifically aimed at preventing lung damage. Its primary function is to prevent alveolar collapse and improve oxygenation.

B. "PEEP will push more air into the lungs during inhalation.": PEEP does not affect the volume of air delivered during inhalation. It helps keep the alveoli open during exhalation, but does not increase the amount of air pushed into the lungs during inhalation.

C. "PEEP prevents the alveoli from collapsing during exhalation.": PEEP applies pressure to the lungs at the end of exhalation, preventing the alveoli from collapsing, which improves oxygenation by maintaining functional residual capacity and enhancing gas exchange.

D. "PEEP allows the breathing machine to deliver 100% O2 to the lungs.": PEEP does not affect the percentage of oxygen delivered. It works to improve oxygenation by keeping the alveoli open, but the fraction of inspired oxygen (FiO2) is what determines the oxygen concentration delivered by the ventilator.

A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

Correct Answer is A

Explanation

A. Respiratory acidosis: Respiratory acidosis occurs when CO2 accumulates due to impaired ventilation, leading to a decrease in pH. The elevated PaCO2 (48 mm Hg) and low pH (7.32) confirm respiratory acidosis. Normal HCO3 (23 mEq/L) suggests no renal compensation at this point.

B. Respiratory alkalosis: Respiratory alkalosis is marked by a decrease in PaCO2, which is not seen here as the PaCO2 is elevated. A low pH further contradicts alkalosis, as it should be elevated. Therefore, respiratory alkalosis is not supported by these ABG values.

C. Metabolic acidosis: Metabolic acidosis shows a decrease in HCO3, which is normal in this case (23 mEq/L). Additionally, the elevated PaCO2 points to a respiratory origin of the acidosis, not a metabolic cause.

D. Metabolic alkalosis: Metabolic alkalosis involves elevated HCO3 and a higher pH, which is not observed here. The bicarbonate level is normal, and the pH is low, ruling out metabolic alkalosis. The primary issue in this case is respiratory acidosis, not metabolic.

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An emergency room nurse is triaging victims of a mass-casualty event. Which client should receive care first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the client's caregiver is accurate?

Correct Answer is C

Explanation

A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate of which of the following acid-base balances?

Correct Answer is A

Explanation

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