Practice Question
A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first?
Answer Choices:
Correct Answer:
An unconscious adult client who has a sucking chest wound, respirations of 38/min, and capillary refill of
Rationale:
✳️ This client is experiencing a life-threatening injury: a sucking chest wound, which can lead to a tension pneumothorax and rapid deterioration.
✳️ Though breathing fast (38/min), the client is unconscious, indicating impaired oxygenation or perfusion.
✳️ In triage, the highest priority goes to those who are unstable but salvageable—this client requires immediate airway management to survive.
✳️ The client in option D has no respirations and failed airway attempts, suggesting they're non-salvageable, placing them in the expectant category.
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This question is from RN ATI Advanced Medsurgical Exam 4 which contains 41 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI MedSurg
- Answer Choices: 4