NCLEX-RN

Category - Care Management

Rick Rescue, RN is performing triage duties for the Emergency Department today. He has assessed four clients and is now prioritizing the order in which they will see the physician. In which order should the following clients be seen?

A. 80-year-old female, complaining of frequent, liquid brown stool.
B. 15-year-old female, complaining of severe pain to her right wrist, with tingling radiating to her hand and fingers, after falling two feet during cheerleading practice. Swelling and bruising to right wrist.
C. 52-year-old, complaining of intermittent pain, in the area behind the right scapula.
21-year-old male, complaining of wheezing with inspiration and facial blistering, after singeing beard and moustache while building a fire.
  1. III, IV, I, II
  2. IV, III, II, I
  3. I, II, III, IV
  4. II, I, IV, III
Explanation
Answer: B - A client close enough to fire or heat to sustain facial blisters and singeing of facial hair may also sustain damage to the lining of the lungs. The possibility of developing respiratory distress is great in this client, and, therefore, he should be seen first. Nurses consider the ABC’s (Airway, Breathing and Circulation) when prioritizing the needs of clients. Life saving measures must be priority.
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