Nursing Prioritization Delegation Assignment Q 84
A client with multiple injuries is rushed to the ED after a head-on car collision. Which assessment finding takes priority?
A. Irregular apical pulse
B. Ecchymosis in the flank area
C. A deviated trachea
D. Unequal pupils
Correct Answer: C. A deviated trachea
A deviated trachea is a symptom of tension pneumothorax, which will result in respiratory arrest if not managed. The first question in the ESI triage algorithm for triage nurses asks whether “the patient requires immediate life-saving interventions” or simply “is the patient dying?” The nurse determines this by looking to see if the patient has a patent airway, if the patient is breathing, and if the patient has a pulse.
Option A: Assessment of circulation comes after the airway. The nurse evaluates the patient, checking pulse, rhythm, rate, and airway patency. Is there concern for inadequate oxygenation? Is this person hemodynamically stable? Does the patient need any immediate medication or interventions to replace volume or blood loss? Does this patient have pulselessness, apnea, severe respiratory distress, oxygen saturation below 90, acute mental status changes, or unresponsiveness?
Option B: Ecchymosis can be a sign of internal bleeding, which belongs to assessment of circulation. If the patient is not categorized as a level 1, the nurse then decides if the patient should wait or not. This is determined by three questions; is the patient in a high-risk situation, confused, lethargic, or disoriented? Or is the patient in severe pain or distress? The high-risk patient is one who could easily deteriorate, one who could have a threat to life, limb, or organ.
Option D: Anisocoria due to trauma may remain permanent but also may improve over time. Surgical management is rarely warranted. A referral to a neuro-ophthalmologist, ophthalmologist, or neurologist may be warranted in cases that do not resolve.