Practice Question
A nurse is caring for clients in an emergency department.
Answer Choices:
Rationale:
🚨 Client 2: Life-Threatening but Survivable Injuries
🔴 Explanation of Priority: Client 2 presents with a sucking chest wound and hypotension (BP 80/52 mm Hg), both of which are immediately life-threatening but potentially reversible with prompt intervention. This makes the client a red-tag (immediate) triage priority under the Emergency Operations Plan (EOP).
🔴 Clinical Reasoning: A sucking chest wound indicates an open pneumothorax, which causes air to enter the pleural space during inspiration, leading to lung collapse and impaired oxygen exchange. This can quickly progress to tension pneumothorax if untreated.
🔴 Expected Nursing Actions: The nurse should immediately apply a vented (three-sided) occlusive dressing to prevent further air entry, administer supplemental oxygen, and prepare for chest tube insertion by the provider.
🔴 Outcome Goal: Early recognition and rapid stabilization can restore adequate ventilation and perfusion, preventing respiratory failure or cardiac arrest.
🔴 Ethical and Triage Significance: In mass casualty triage, clients with critical but treatable injuries receive top priority, as timely intervention offers the best chance for survival while maximizing limited resources.
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This question is from RN Concept Based Level Assessment 4 which contains 140 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN Concept-Based Assessment Level Exam(s)
- Answer Choices: 0