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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale

Referring to a support group is beneficial for long-term coping but does not address the immediate emotional impact of grief, which requires attentive listening and empathy to support the client emotionally.

Choice B rationale

Viewing the deceased's body might help with closure, but it should only be encouraged when the client feels ready. The priority is assessing emotional readiness and supporting them empathetically at that moment.

Choice C rationale

Building new relationships promotes long-term healing, yet it is premature at this stage of grief. Clients require acknowledgment of their immediate loss and support for their acute emotional response first.

Choice D rationale

Sharing thoughts and feelings facilitates emotional expression, which is critical in the acute phase of grief. It helps the client process the loss, providing an essential foundation for emotional support and further interventions.

A. Administer antibiotic therapy to the client. B. Provide the client with analgesics as needed. C. Initiate droplet precautions for the client. D. Educate the client about the meningococcal infection.

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has just learned that their partner died. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is admitting a client who has meningococcal meningitis. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is teaching a client about the correct use of a cane. Which of the following instructions should the nurse include in the teaching?

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