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 A

Explanation

A. Difficulty swallowing: Difficulty swallowing in a client with burns to the face, ears, and eyelids may indicate swelling or airway compromise. Swelling of the oral cavity, throat, or airway can lead to obstruction, which is life-threatening. This requires immediate reporting.

B. Urinary output 25 mL/hr: Urinary output of 25 mL/h is slightly below the expected 30 mL/h but may be due to fluid shifts post-burn injury. While concerning, it does not represent an immediate life-threatening issue.

C. Pain of 6 on a scale of 0 to 10: Pain management is crucial in burn care, but a pain level of 6 is moderate and manageable with medications. It does not indicate a life-threatening condition. Managing airway and potential swallowing difficulties should take priority.

D. Heart rate 122/min: A heart rate of 122/min can result from pain, stress, or hypovolemia, common in burn victims. While tachycardia requires monitoring, it is not as urgent as airway compromise.

A. Start an IV infusion of lactated Ringer's B. Give morphine IV. C. Administer high flow oxygen therapy D. Initiate cardiac monitoring

Correct Answer is C

Explanation

A. Start an IV infusion of lactated Ringer's: Fluid resuscitation is not the immediate priority in a pulmonary embolism. The first concern is oxygenation. The client’s low oxygen saturation (88%) suggests that oxygen therapy should be the first intervention to stabilize the client.

B. Give morphine IV: Morphine can help manage pain and reduce anxiety, which may aid in improving breathing, but it is not the immediate priority. Administering high-flow oxygen is crucial address the client's hypoxia, which poses a more immediate threat.

C. Administer high flow oxygen therapy: Pulmonary embolism causes impaired gas exchange due to blockage in the pulmonary arteries, leading to low oxygen levels. Administering high-flow oxygen is the first priority to improve oxygenation, stabilize the client, and prevent further complications.

D. Initiate cardiac monitoring: While cardiac monitoring is important in monitoring the client’s condition, especially if there is concern for arrhythmias, the priority is to first stabilize the client’s oxygen levels.

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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

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?

Correct Answer is A

Explanation

A nurse is caring for a client who develops a pulmonary embolism: BP 158/68, pulse 98, respirations 26, pulse oximetry 88%. Which of the following interventions should the nurse implement first?

Correct Answer is C

Explanation

A nurse is caring for a client who has the following arterial blood gas results: HCO3 18 mEq, PaCO2 28 mm Hg and pH 7.30. The nurse recognizes the client is experiencing which of the following acid-base imbalances?

A nurse is caring for a client who has heart failure and is experiencing ventricular dysrhythmias. The nurse should identify which of the following as the cause of the client's dysrhythmias?

A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid- based imbalances should the nurse identify the client as being at risk for developing initially?

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock?

A nurse is reviewing the PT/INR and aPTT laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?

A nurse is working with an emergency response team in caring for a group of people who may have been exposed to anthrax while doing farm work. Which of the following is the appropriate action for the nurse to take?

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which two of the following findings should the nurse identify as a late sign of ICP? (Select all that apply)