The nurse is helping triage in the emergency department as victims of an explosion are being brought in. Rank (1–5) the following patients according to their need for priority treatment according to disaster response protocols and best chance of survival
A. _____ A 15-year-old with a laceration to the foot that is bleeding slightly
B. _____ A 36-year-old who has no pulse or respirations and has an open head injury
C. _____ A 70-year-old with shortness of breath but no detectable cardiac arrhythmias
D. _____ A 5-year-old with a suspected fracture of the humerus
E. _____ A 58-year-old woman with a distended abdomen who reports severe abdominal pain
ANS:
C, E, D, A, B
Patients who are seriously injured and have the greatest chance of full recovery are treated first. This would be the patient with shortness of breath without any cardiac arrhythmia. The next patient would be the patient with a distended abdomen reporting abdominal pain. The child with a fractured humerus should be treated next. The patient with the foot laceration then be treated. The patient without any pulse or respirations could be seen last.
You might also like to view...
A patient recovering from a partial spinal cord lesion is experiencing muscle spasticity. Relative to this complication, what is the nursing priority?
A) Monitor neurologic status every 4 hours B) Ensure compliance with exercise program C) Medicate often for pain and discomfort D) Emphasize nutritional balance
The nurse providing education for a client who is having external radiation therapy should include which of these points?
a. Side effects are usually minimal. b. Hospitalization is required for the duration of treatment. c. Radiation will eradicate cancer from the body. d. Side effects may not occur until after treat-ment is completed.
Which of the following actions is considered a nurse-initiated intervention?
1. administering medications to a client 2. inserting a catheter per physician's orders 3. managing a client's medically restricted diet 4. addressing a client's fears prior to surgery
Which assessment would not be included with a 17-year-old's screening during a routine health supervision visit?
1. STI evaluation 2. Autism screening 3. Hemoglobin test 4. Vision screening