Who should the nurse assign the highest priority to?
Four clients injured in an automobile accident enter the emergency department at the same time. The triage nurse evaluates them immediately.
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A. Lumbar spinal cord injury and lower extremity paralysis. B. Maxillofacial injury and gurgling respirations. C. Severe head injury and no blood pressure. D. Second-trimester pregnancy in premature labor.
In this situation when it comes to first priority, the first person that should be treated is the one with the major facial injury with gurgling. This is someone who is in the most distress. The spinal cord injury could easily have the person stable because the rest of their body could be functioning.
The second-trimester pregnancy is something that is already known and doctors there could take care of the problems already. The severe head injury with no blood pressure most likely means that the person is already dead. Therefore the facial injury would be first because it is something that needs immediate attention the most.
Maxillofacial injury and gurgling respirations.-rationale: emergency department triage involves giving priority to clients at highest risk for loss of life, limb, or vision. clients with poor prognoses are given a lesser priority. the client with the maxillofacial injury and gurgling respirations needs immediate attention because of an impaired airway. the spinal cord injury client doesnt exhibit immediate airway needs. the client with the severe head injury and no blood pressure has a grave prognosis. although the client in early labor is an urgent priority, early labor doesnt surpass airway compromise in importance.client needs category: physiological integrityclient needs subcategory: physiological adaptationcognitive level: analysisreference: smeltzer, s.c., and bare, b. brunner & suddarths textbook of medical surgical-nursing, 11th ed. philadelphia: lippincott williams & wilkins, 2008, p. 2561.