The following clients come to the emergency department for treatment after a building explosion and collapse. Which client should receive priority care?

An unresponsive client who arrives with third-degree burns over 95% of her body.

A client with an open head injury: pupils are fixed and dilated

A client with a severed left leg and bleeding at the severance site.

A client with a small leg laceration who is otherwise stable.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Although this client has extensive injuries, her prognosis is extremely poor. According to triage principles in mass-casualty situations, clients with unsurvivable injuries are classified as expectant. They receive comfort care, but immediate life-saving interventions are unlikely to succeed.

B. Fixed and dilated pupils indicate severe brain injury with a poor prognosis. Like the client with massive burns, this client is considered expectant in a mass-casualty triage scenario. Immediate intervention is unlikely to improve survival.

C. This client has a life-threatening but potentially survivable injury. Rapid control of hemorrhage can save the client’s life. According to triage principles, clients with airway compromise, severe bleeding, or shock who are likely to survive with prompt treatment are prioritized for immediate care.

D. This client’s injury is minor and does not pose an immediate threat to life. They can safely wait for care after more critical patients are stabilized.

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Correct Answer is ["C","D","E"]

Explanation

Rationale:

A. While obtaining a medical history is important, it is not part of the primary survey. In a life-threatening trauma situation, history is secondary to immediate life-saving interventions. History is collected after the patient is stabilized (secondary survey).

B. Preventing hypothermia is part of trauma care and important, but it is considered a secondary or adjunct intervention after immediate threats to life are addressed. It is not a primary survey priority.

C. Controlling bleeding is a primary survey priority. Severe hemorrhage can rapidly lead to hypovolemic shock and death, so it must be addressed immediately using direct pressure, tourniquets, or other interventions.

D. Airway is the first priority in the primary survey (A in ABCs: Airway, Breathing, Circulation). Ensuring the airway is patent prevents hypoxia and is essential for survival in trauma patients.

E. After ensuring the airway is open, the next priority is breathing (B in ABCs). Assessing and supporting ventilation ensures adequate oxygenation and carbon dioxide elimination. This may involve supplemental oxygen, bag-mask ventilation, or intubation if necessary.

A. Diarrhea B. Presence of a pressure ulcer C. Kinked urinary catheter tubing D. Fecal impaction E. Respiratory congestion

Correct Answer is ["B","C","D"]

Explanation

Rationale:

A. While diarrhea is a gastrointestinal symptom, it is not a common trigger for autonomic dysreflexia (AD). AD is usually precipitated by a noxious stimulus below the level of spinal cord injury, typically related to bladder or bowel distention or skin irritation.

B. Pressure ulcers create a painful or noxious stimulus below the level of injury, which can trigger autonomic dysreflexia. The body responds with sudden sympathetic overactivity, causing hypertension, headache, sweating, and flushing above the level of injury.

C. A blocked or kinked urinary catheter causes bladder distention, the most common trigger for AD. The distention sends afferent signals to the spinal cord, resulting in uncontrolled sympathetic responses. Immediate catheter assessment and correction are critical to resolve the episode.

D. Bowel distention from fecal impaction is a frequent cause of AD. Like bladder distention, it provides a noxious stimulus below the injury level, triggering hypertension, bradycardia, headache, and sweating. Prompt removal of the impaction alleviates the dysreflexic episode.

E. While respiratory issues are important to monitor, they are not a typical trigger for autonomic dysreflexia. AD is usually initiated by stimuli below the level of the spinal cord injury, particularly involving the bladder, bowel, or skin.

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The following clients come to the emergency department for treatment after a building explosion and collapse. Which client should receive priority care?

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Naxlex Comprehensive Predictor Exams

What should the emergency department nurse identify as a PRIMARY survey clinical priorities for the treatment of a client with a gunshot wound? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

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Correct Answer is ["B","C","D"]

Explanation

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