Thursday, December 28, 2023

A triage nurse has these four (4) clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first



A triage nurse has these four (4) clients arrive in the emergency .department within 15 minutes.

Which client should the triage nurse send back to be seen first?


  • A- A 2-month-old infant with a history of rolling off the bed and has bulging fontanels with crying
  • B- A teenager who got a singed beard while camping
  • C- An elderly client with complaints of frequent liquid brown colored stools
  • D- A middle-aged client with intermittent pain behind the right scapula

Answer: B:

A teenager who got signed beard while camping. This client is in the greatest danger with a potential of respiratory distress. Any client with singed facial hair has been exposed to heat or fire in close range that could have caused serious damage to the interior of the lungs. Note that the interior lining of the lungs have no nerve fibers so the client will not be aware of swelling.

Caring for someone in respiratory distress:

A nurse can care for a person in respiratory distress in a variety of ways, depending on the severity of the situation and the resources available.

Immediate care:

  • Assess the person's airway, breathing, and circulation. This is known as the ABCs of emergency care.
  • If the person is unconscious, check for a pulse and breathing. If the person is not breathing, start CPR.
  • If the person's airway is blocked, try to clear it by gently tilting their head back and lifting their chin. If the person is conscious, you may also be able to clear the airway by having them cough or by using a suction device.
  • If the person is having trouble breathing, administer oxygen as needed. Oxygen can be delivered through a nasal cannula, face mask, or non-rebreather mask.
  • If the person is in severe respiratory distress, they may need to be intubated and placed on a ventilator. Intubation is a procedure that involves inserting a tube into the trachea (windpipe) to help the person breathe.

Ongoing care:

  • Monitor the person's vital signs, including their respiratory rate, heart rate, blood pressure, and oxygen saturation.
  • Provide the person with supplemental oxygen as needed.
  • Administer medications as prescribed by the doctor. This may include medications to bronchodilate (open up the airways), reduce inflammation, or treat the underlying cause of the respiratory distress, such as an infection or allergic reaction.
  • Position the person in a way that makes it easier for them to breathe. This may involve sitting them up or having them lie on their side.
  • Encourage the person to cough up any secretions. This will help to clear the airways and prevent pneumonia.
  • Provide emotional support to the person and their family. Respiratory distress can be a very frightening experience, so it is important to be there for the person and to offer them your support.
The nurse will also work closely with the doctor to develop a treatment plan for the person. The treatment plan will be based on the underlying cause of the respiratory distress and the person's individual needs.

Additional things to care for someone in respiratory distress:

Here are some additional things a nurse can do to care for a person in respiratory distress:
  • Keep the person's airway moist. This can be done by using a humidifier or by having the person breathe in steam from a shower or bowl of hot water.
  • Monitor the person's fluid intake and output. It is important to make sure that the person is not getting too much or too little fluid.
  • Provide the person with nutritional support. This may involve giving them food and drinks orally, or it may involve providing them with nutrients through an intravenous (IV) line.
  • Help the person to ambulate as soon as possible. This will help to prevent pneumonia and other complications.
  • Educate the person and their family about respiratory distress and how to manage it at home. This will help the person to prevent future episodes of respiratory distress and to be prepared if an episode does occur.
Nurses play a vital role in the care of people with respiratory distress. By providing prompt and effective care, nurses can help to improve the person's outcome and prevent complications.