The nurse is triaging four clients injured in a car crash.
Which client should receive priority treatment?
42-year-old with dyspnea and chest asymmetry.
4-year-old with facial lacerations.
30-year-old with blunt abdominal trauma.
17-year-old with a fractured arm.
The Correct Answer is A
Choice A rationale
The 42-year-old client exhibits signs of a potential tension pneumothorax or flail chest, evidenced by dyspnea and chest asymmetry. In trauma triage, airway and breathing take absolute precedence over other injuries. Chest asymmetry suggests a major mechanical disruption of ventilation that can quickly lead to respiratory arrest or obstructive shock. This client requires immediate assessment and intervention, such as chest tube insertion or needle decompression, to stabilize their breathing and ensure adequate systemic oxygenation.
Choice B rationale
Facial lacerations in a 4-year-old are distressing but usually do not represent an immediate threat to life unless the airway is obstructed by blood or edema. If the child is crying and breathing, the airway is currently patent. While pediatric patients are often prioritized due to their physiological vulnerability, the mechanical respiratory distress seen in the adult client with chest asymmetry is a more urgent clinical priority. Lacerations can be managed after the primary survey and stabilization of breathing.
Choice C rationale
Blunt abdominal trauma in a 30-year-old carries a risk for internal hemorrhage and organ rupture. This client requires close monitoring of vital signs and possibly an ultrasound or CT scan. While potentially life-threatening if the client enters hemorrhagic shock, the immediate airway and breathing compromise in the client with chest asymmetry is a higher priority. In the ABCDE triage sequence, breathing issues are addressed before circulatory issues like potential abdominal bleeding are fully managed.
Choice D rationale
A fractured arm in a 17-year-old is generally considered a non-urgent or "green tag" injury in a mass casualty or trauma triage setting, provided there is no massive external hemorrhage. Although the client is in pain and requires splinting and imaging, this musculoskeletal injury does not compromise the airway, breathing, or overall hemodynamic stability. This client can wait for treatment while more critically injured individuals with respiratory or circulatory distress are stabilized by the medical team.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Step 1 is (5,000 mL × 0.5) = 2,500 mL.
Step 2 is 2,500 mL should be given in the first 8 hours.
Step 3 is 3: p.m. to 10: p.m. is 7 hours.
Step 4 is the first 8 hours are calculated from the time of injury which was 2: p.m.
Step 5 is the first 8-hour period ends at 10: p.m.
Step 6 is the total amount to be received by 10: p.m. is 2,500 mL
Correct Answer is D
Explanation
Choice A rationale
This description more accurately reflects the function of pressure support or tidal volume settings on a ventilator. Positive end-expiratory pressure does not focus on the inspiratory phase or pushing air in; instead, it acts during the expiratory phase. The goal is to maintain a specific level of pressure within the circuit at the end of a breath to ensure that the internal architecture of the lung remains open for gas exchange.
Choice B rationale
While PEEP is vital in managing the symptoms of ARDS and improving oxygenation, it does not directly prevent the underlying inflammatory processes that lead to lung fibrosis. Fibrosis is a late-stage complication of the proliferative phase of ARDS characterized by the excessive deposition of collagen. PEEP is a supportive measure to manage alveolar recruitment and oxygenation rather than a curative treatment that halts the cellular progression toward permanent scarring.
Choice C rationale
PEEP is a pressure setting, not a measure of the fraction of inspired oxygen. The delivery of 100 percent oxygen refers to the FiO2 setting. While PEEP can help improve the efficiency of oxygenation, allowing for a lower FiO2 to be used to achieve adequate arterial oxygen levels, it is not the mechanism that delivers the oxygen itself. Its primary function is mechanical stabilization of the alveolar units during the breathing cycle.
Choice D rationale
In ARDS, fluid leakage and loss of surfactant cause alveoli to become unstable and collapse, a process known as atelectasis. PEEP provides constant pressure at the end of exhalation to keep these air sacs open, which increases the surface area available for gas exchange and improves arterial oxygenation. By preventing repetitive opening and closing of alveoli, PEEP also helps reduce ventilator-induced lung injury, which is a common risk in severe respiratory failure.
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