REMAR- Priority Practice
The nurse on a pediatric unit has received report on four clients. The nurse should first
plan to assess which client first?
A. A 9 years old, has a fracture of the radial bone and is reporting pain rated 8 on a pain
scale of 0 to 10.
B. A 5 years old with a history of asthma and has a peak expiratory flow rate of 83%
C. A 3 years old client with a temperature of 99.7 and a blood pressure of 70/45.
D. A 7 years old with ulcerative colitis and has had 16 blood tinged stools in the last 24
hours. - CORRECT ANSWER-C.
The child experiencing fever and hypotension should be seen first, they are at the
highest risk in this situation for hypovolemic shock; the average blood pressure for a
toddler is 92/56. The child with asthma is not acutely ill at this time; pain is expected
with a bone fracture, management of pain is important
but does not take priority; ulcerative colitis is expected to produce 10 - 20 bloody stools
per day, this is not the priority in this situation.
A nurse is working triage during an external disaster. When assessing adequate
breathing in a patient, she should look for which of the following?
A. Look for chest rise.
B. Listen for air exchange.
C. Feel for abdominal movement.
D. All of the above. - CORRECT ANSWER-D
All of the techniques should be utilized in the field. Nurse should observe the rise and
fall of the chest (inspiration and expiration) - this counts as one breath;
The respirations should be counted for a full minute in order to have an accurate
recording. Air exchange should be recorded. Note the pattern of breathing and the
depth of the breaths while feeling for abdominal movement.
The nurse has received 4 clients from a house fire. Which patient should she see first?
A. The client who is unconscious, pulseless, and has dilated pupils.
B. The client who has the tibia bone protruding through the skin and is in severe pain.
C. The client who has soot on the face and the nares and is coughing.
D. The client who has third degree burns of the left foot and is crying. - CORRECT
ANSWER-C
The client with soot on the face and nose may have a potential airway problem. After a
disaster clients are seen in order of priority. Those with life threatening injuries who are
likely to survive are seen first. Those that require immediate care, who can be evaluated
within 2 hours, are seen next. Next are clients who could wait hours to days before
treatment.
A nurse is working an external disaster scene. He knows to reduce the anxiety of a
victim he can:
