The emergency department triage nurse receives notification there has been a mass shooting incident at a local shopping mall with several casualties injured. The hospital’s emergency response plan is initiated. Which client should the nurse prioritize for care?
Client with a sucking chest wound, conscious, blood pressure 88/58 mm Hg, heart rate 115/min, and red tag observed.
Client with a significant penetrating head wound, unconscious with irregular breathing pattern, and black tag observed.
Client with superficial lacerations to the left arm and left lower leg.
Client with closed left lower leg injury, air cast in place, pain reported as 9 on a 0 to 10 numeric pain scale.
The Correct Answer is A
Choice A rationale
A sucking chest wound compromises breathing, causes tension pneumothorax, and decreases cardiac output. Hypotension (88/58 mm Hg) and tachycardia (115/min) indicate shock, warranting immediate intervention. Red tag signifies life-threatening but potentially survivable injuries.
Choice B rationale
Penetrating head wounds with irregular breathing suggest brainstem injury, poor prognosis, and impending death. Black tag indicates un-survivable injuries, prioritizing resource allocation to others with a better survival potential.
Choice C rationale
Superficial lacerations involve minor soft tissue damage that does not compromise vital functions. These injuries are non-life-threatening and can wait for delayed medical care without significant risk to life or function.
Choice D rationale
Closed lower leg injuries cause localized pain but do not compromise airway, breathing, or circulation. Pain severity does not indicate life-threatening harm, allowing delayed care. Yellow tag signifies urgent but not immediate need for treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Encouraging the client to share their thoughts fosters therapeutic communication. This approach builds trust, explores underlying concerns, and allows the nurse to provide education and address misconceptions effectively.
Choice B rationale
Suggesting regret minimizes the client’s autonomy and could create feelings of guilt. This response is not client-centered and does not support an open, respectful discussion about their decision-making process.
Choice C rationale
Stating it is too late dismisses the client’s right to autonomy. This response is not accurate as procedures can typically be postponed, and it discourages open communication about the client’s concerns.
Choice D rationale
Reassuring about the painlessness of surgery dismisses the client’s feelings and does not address their specific concerns. This response may oversimplify the situation, leading to reduced trust and rapport.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Shaking the inhaler before use ensures medication mixing for accurate dosing. Without agitation, active ingredients may separate, delivering inconsistent or inadequate amounts of the drug.
Choice B rationale
Holding the breath for 10 seconds post-inhalation promotes medication deposition in distal airways, enhancing efficacy. This pause allows gravitational and diffusional medication settling in alveoli.
Choice C rationale
Deep inhalation through the mouth optimizes medication delivery to lower respiratory tracts. Shallow breathing or nasal inhalation can reduce penetration, limiting therapeutic effects.
Choice D rationale
Holding the inhaler 2 inches from the mouth diminishes medication delivery efficiency. Proper technique involves creating a seal with lips around the mouthpiece to direct aerosolized medication into the lungs.
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