Your ED is receiving 44 casualties following a tornado strike.
A patient with no pulse or respirations should be triaged to which area?
Emergency department for life-saving measures.
Off-site clinic for walking wounded.
Minor care area for minimal patient care.
Holding area/hospital morgue for non-salvageable injuries.
The Correct Answer is D
Choice A rationale
The emergency department is reserved for red-tagged patients who require immediate life-saving interventions for salvageable conditions. During a mass casualty incident with 44 casualties, resources are extremely limited and must be allocated to those with the highest probability of survival. A patient with no pulse or respirations is physiologically deceased or non-salvageable in a disaster context. Performing resuscitation on such individuals would divert critical staff and equipment away from salvageable victims.
Choice B rationale
Off-site clinics for the walking wounded are designated for green-tagged patients who have minor injuries such as abrasions, small lacerations, or simple fractures. These individuals are hemodynamically stable and capable of ambulation. A patient lacking a pulse or spontaneous respirations does not meet the criteria for minor care. Such patients require no further medical intervention in a triage system designed to maximize the number of survivors within a population during a disaster.
Choice C rationale
Minor care areas are intended for patients with non-life-threatening injuries that can wait for treatment without significant risk of clinical deterioration. Examples include simple sprains or minor burns. Because this patient is already in a state of cardiopulmonary arrest, there is no physiological baseline to maintain in a minor care setting. Triage protocols mandate that those who are already deceased or have injuries incompatible with life be bypassed to prioritize active treatment.
Choice D rationale
In disaster triage, the black tag category is used for patients who are either deceased or have injuries so severe that survival is unlikely even with maximal care. This patient has no pulse or respirations, meeting the criteria for being non-salvageable. Moving them to a morgue or holding area allows the medical team to focus exclusively on those with a chance of survival, adhering to the ethical principle of providing the greatest good for the greatest number.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["200"]
Explanation
Answer and explanation
5 Step 1 is (100 ml ÷ 30 min) × 60 min.
Step 2 is 200 ml.
Correct Answer is A
Explanation
Choice A rationale
Severe sepsis triggers systemic vasodilation and increased capillary permeability, leading to absolute and relative hypovolemia. Restoring circulating blood volume is the highest priority to maintain organ perfusion and prevent irreversible cellular damage. Isotonic fluids, such as 0.9 percent normal saline or lactated Ringer solution, provide immediate intravascular expansion. Stabilizing the blood pressure, currently 80/50 mm Hg, takes precedence over all other interventions in the initial hour of sepsis management to ensure oxygen delivery to vital tissues.
Choice B rationale
Acetaminophen is indicated for the patient's temperature of 102 degrees F to reduce metabolic demand and improve comfort. However, hyperthermia is a physiological response to infection and is not immediately life-threatening compared to profound hypotension and shock. Administering a suppository does not address the underlying hemodynamic instability or the systemic inflammatory response. While necessary for supportive care, it is a lower priority than fluid resuscitation and starting antimicrobial therapy in the emergency setting.
Choice C rationale
Obtaining blood cultures from two different sites is a critical step in identifying the causative pathogen and guiding targeted antibiotic therapy. This should ideally be performed before the administration of antibiotics to increase the yield of the cultures. However, in the presence of severe hypotension, hemodynamic stabilization through fluid administration is the most urgent action. While cultures are essential for long-term management, the immediate survival of the patient depends on correcting the distributive shock state.
Choice D rationale
Broad-spectrum antibiotics are vital for treating the underlying infection in sepsis and should be administered as soon as possible, ideally within one hour of recognition. Delayed administration is associated with increased mortality. Nevertheless, if the patient is severely hypotensive, the physiological priority is to fill the vascular bed first. Fluids and antibiotics are often started near-simultaneously, but the nurse must ensure the bolus is initiated to provide the pressure needed to circulate the medications effectively.
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