You are field triaging clients after an industrial accident. Which client condition would you triage with a red tag?
Dislocated right hip and an open fracture of the right lower leg
Closed fracture of the right clavicle and arm numbness
Large contusion to the forehead and a bloody nose
Multiple fractured ribs and shortness of breath
The Correct Answer is D
Rationale:
A. While these injuries are serious, they are not immediately life-threatening. The patient can generally wait for treatment without immediate risk of death, so they would likely be triaged yellow (delayed).
B. A closed clavicle fracture with mild neurologic symptoms is significant but not immediately life-threatening, so the patient would also be triaged yellow or green depending on mobility and stability.
C. A forehead contusion and epistaxis are usually minor injuries unless accompanied by altered consciousness or other complications. These patients are generally triaged green (minor).
D. Rib fractures combined with respiratory compromise such as shortness of breath indicate a potential life-threatening injury, such as flail chest or pulmonary contusion. These patients require immediate intervention to stabilize airway and breathing, making a red tag (immediate priority) appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Pulmonary embolism can cause sudden shortness of breath and tachypnea; however, in this trauma context, a PE is less likely immediately upon arrival unless the patient had a pre-existing clot. The acute presentation of trauma with hypotension and low hemoglobin makes internal thoracic or pulmonary injury more probable.
B. MI may cause dyspnea, chest pain, and hypotension, but the mechanism of injury (high-speed MVC with dashboard impact) and the rapid, shallow breathing pattern suggest trauma-related thoracic injury rather than a primary cardiac event.
C. The patient’s shallow, rapid respirations, hypotension, tachycardia, hypoxia, and decreased level of consciousness are classic signs of thoracic injury such as pneumothorax or hemothorax. The mechanism of injury—a high-speed frontal impact with steering wheel intrusion and seat belt trauma—places her at high risk for rib fractures, lung contusions, and accumulation of air or blood in the pleural space. These injuries restrict lung expansion, leading to rapid, shallow respirations as the patient attempts to maintain oxygenation. The low hemoglobin further suggests blood loss, consistent with hemothorax.
D. While TBI can alter breathing patterns (e.g., Cheyne-Stokes, irregular respirations), the patient’s primary pattern is rapid and shallow, more consistent with thoracic compromise rather than central neurologic injury. Additionally, the hypotension and low hemoglobin support blood loss as a primary factor rather than isolated neurologic dysfunction.
Correct Answer is B
Explanation
Rationale:
A. This is not the immediate priority. While surgical consultation may be necessary later for trauma care, the client is in cardiac arrest, and immediate life-saving interventions take precedence.
B. Personal protective equipment (PPE) protects healthcare providers from exposure to bloodborne pathogens and other infectious materials, which is crucial before performing high-risk procedures such as cardiopulmonary resuscitation (CPR) on a patient with multiple open wounds. Ensuring provider safety allows effective and uninterrupted resuscitation.
C. Gathering history is important for trauma assessment, but it is secondary to initiating life-saving interventions. In cardiac arrest, immediate resuscitation (ACLS) must begin while brief relevant information is obtained concurrently if possible.
D. In the emergency department, the patient is already under emergency care. Rapid Response Teams are typically used in inpatient units to respond to acute deterioration. For a patient in cardiac arrest in the ED, immediate initiation of ACLS protocols is the priority over notification.
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