A client is brought to the Emergency Department as one of the first victims of a train accident. The client reports light-headedness, a weak pulse, and uncontrolled bleeding. Which priority tag should a triage nurse use to categorize this client?
Black tag
Red tag
Green tag
Yellow tag
The Correct Answer is B
Choice A reason: A black tag is not the appropriate priority tag for this client, as it indicates that the client is dead or has injuries that are incompatible with life. A black tag is used for clients who have no signs of life, such as pulse, respiration, or pupillary response, or who have severe injuries that cannot be treated with the available resources, such as massive head trauma, decapitation, or incineration. A black tag means that no further care or intervention is provided to the client.
Choice B reason: A red tag is the appropriate priority tag for this client, as it indicates that the client has life-threatening injuries that require immediate attention and treatment. A red tag is used for clients who have compromised airway, breathing, or circulation, such as respiratory distress, shock, severe bleeding, chest pain, or head injury. A red tag means that the client is given the highest priority and is treated as soon as possible.
Choice C reason: A green tag is not the appropriate priority tag for this client, as it indicates that the client has minor injuries that do not require urgent care or intervention. A green tag is used for clients who have stable vital signs and can walk or move without assistance, such as abrasions, sprains, fractures, or minor burns. A green tag means that the client is given the lowest priority and is treated after all other clients.
Choice D reason: A yellow tag is not the appropriate priority tag for this client, as it indicates that the client has serious injuries that require observation and treatment within a short time frame. A yellow tag is used for clients who have potential complications or deterioration of their condition, such as abdominal pain, pelvic injury, open wounds, or spinal injury. A yellow tag means that the client is given the second highest priority and is treated within 30 to 60 minutes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Giving care with a focus on the aggregate's needs is not the best description of client-focused community-based nursing, as it implies that the nurse is providing care to a population or a group of individuals who share some common characteristics or risk factors. This is more aligned with the concept of population-focused community-based nursing, which aims to improve the health outcomes of a defined group of people.
Choice B reason: A philosophy that guides family-centered illness care is the best description of client-focused community-based nursing, as it reflects the core values and principles of this approach. Client-focused community-based nursing is a model of care that emphasizes the individual and family as the unit of care, rather than the disease or the health problem. It involves collaborating with the client and family to identify their needs, preferences, strengths, and resources, and providing holistic, culturally sensitive, and evidence-based care that promotes health, wellness, and quality of life.
Choice C reason: Providing care with a focus on the group's needs is not the best description of client-focused community-based nursing, as it suggests that the nurse is providing care to a collective or a social unit that shares some common goals or interests. This is more aligned with the concept of community-oriented community-based nursing, which aims to improve the health status of a specific community or subpopulation.
Choice D reason: A value system in which all clients receive optimal care is not the best description of client-focused community-based nursing, as it does not capture the essence or uniqueness of this approach. While it is true that client-focused community-based nursing strives to provide high-quality care to all clients, it also recognizes that each client and family has different needs, preferences, and expectations that require individualized and tailored interventions.
Correct Answer is D
Explanation
Choice A reason: The AP's ability to complete the task without assistance is not one of the five rights of delegation. The nurse is responsible for providing adequate supervision and guidance to the AP, and ensuring that the task is done correctly and safely.
Choice B reason: The AP's ability to prioritize is not one of the five rights of delegation. The nurse is responsible for assigning tasks based on their urgency and importance and communicating clear expectations and deadlines to the AP.
Choice C reason: The AP's rapport with clients is not one of the five rights of delegation. The nurse is responsible for maintaining a therapeutic relationship with clients and respecting their preferences and needs.
Choice D reason: The AP has the knowledge and skill to perform the task is one of the five rights of delegation. The nurse is responsible for assessing the AP's competence and readiness to perform the task, and providing appropriate training and feedback if needed.
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