Question

A nurse in an emergency department is triaging clients following an explosion at a local factory. Which of the following clients should the nurse identify as the priority?

1. A client who has tracheal deviation and shortness of breath.
2. A client with a minor laceration on the arm.
3. A client with a fractured arm requesting pain medication.
4. A client with a sprained ankle and mild discomfort.

Answer 1

The client with tracheal deviation and shortness of breath should be prioritized as it can indicate a life-threatening condition such as tension pneumothorax.

Step-by-step explanation:

When triaging clients following an explosion, the nurse must quickly determine which injuries are most life-threatening and prioritize care accordingly. Among the clients mentioned, the one with tracheal deviation and shortness of breath should be considered the highest priority. This condition is indicative of tension pneumothorax, a condition where air is trapped in the pleural space and cannot escape, leading to a collapsed lung. If left untreated, it can quickly become fatal due to leading to impaired venous return to the heart and reduced cardiac output.

Clients with a minor laceration on the arm, a fractured arm requesting pain medication, or a sprained ankle with mild discomfort should also receive treatment but are not considered immediate life threats and can be prioritized accordingly after more critical injuries are addressed.