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 B
Explanation
Choice A rationale
Exercising close to bedtime increases adrenaline and body temperature, which interfere with sleep initiation. Studies recommend ceasing vigorous activity at least 3-4 hours before bedtime to optimize sleep quality.
Choice B rationale
Reducing fluid intake before bed minimizes nocturia, a common sleep disturbance. This aligns with promoting uninterrupted sleep and improving overall sleep hygiene and quality for individuals with insomnia.
Choice C rationale
Taking daytime naps, especially longer than 30 minutes, disrupts circadian rhythms and sleep drive, contributing to difficulty initiating and maintaining sleep during regular hours.
Choice D rationale
Eating a large meal before bedtime delays gastric emptying and may cause discomfort or reflux, both of which interfere with falling asleep. Light snacks are recommended if needed, but not heavy meals.
Correct Answer is B
Explanation
Choice A rationale
Monitoring blood pressure trends ensures early detection of medication effectiveness, yet is secondary to addressing critical hypokalemia. Normal blood pressure is 120/80 mmHg; deviations warrant monitoring, but this is not the priority intervention.
Choice B rationale
Administering potassium chloride STAT addresses potential hypokalemia, which risks arrhythmias and muscle weakness. Normal potassium levels range between 3.5-5.0 mEq/L, highlighting urgency when potassium is below normal.
Choice C rationale
Reassessing additional medication needs at a set time ensures comprehensive care but does not address immediate life-threatening conditions like hypokalemia, which requires urgent correction to prevent cardiac dysfunction.
Choice D rationale
Educating about blood pressure maintenance is crucial for long-term management but does not address the immediate physiological imbalance or risk of arrhythmias due to electrolyte disturbance, making it a lower priority.
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