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 D
Explanation
Choice A rationale
Documenting emesis describes an observed occurrence but does not involve actively performing an intervention, thus representing assessment rather than implementation in client care.
Choice B rationale
Reporting pain as a numeric scale is part of assessment and data collection, not active implementation of nursing interventions aimed at client care.
Choice C rationale
Reporting the absence of nausea or vomiting indicates evaluation of an intervention's effectiveness, which occurs after implementation rather than during it.
Choice D rationale
Contacting the provider actively initiates communication and implementation of interventions, addressing client needs and collaborating with the healthcare team for enhanced care delivery.
Correct Answer is C
Explanation
Choice A rationale
Administering antibiotics is crucial for meningitis management but should follow infection control protocols to prevent transmission, aligning with the prioritization of safety in Maslow's hierarchy of needs.
Choice B rationale
Providing analgesics manages symptoms but does not prevent disease spread. Initiating precautions addresses the immediate risk of contagion, which takes precedence in infection control.
Choice C rationale
Initiating droplet precautions minimizes the risk of disease transmission to healthcare providers and others, adhering to infection control standards and being the primary action in meningococcal meningitis.
Choice D rationale
Educating the client is important for understanding the illness, but immediate containment of the infectious agent through precautions is the priority in preventing disease spread.
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