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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Discipline in the school setting for improper handwashing is not an appropriate action by the nurse, as it may not prevent the spread of influenza or promote healthy behaviors. Influenza is a viral infection that affects the respiratory system and can be transmitted by direct or indirect contact with respiratory droplets from an infected person. Handwashing is one of the most effective ways to prevent the transmission of influenza and other infectious diseases, but it requires proper technique, frequency, and duration. The nurse should not punish or blame the students for their handwashing habits but rather educate and encourage them to wash their hands with soap and water for at least 20 seconds, especially before and after eating, after using the bathroom, after coughing or sneezing, and after touching potentially contaminated surfaces.
Choice B reason: Education regarding respiratory and hand hygiene is an appropriate action by the nurse, as it helps to prevent the spread of influenza and promote healthy behaviors. The nurse should provide accurate and relevant information to the students, staff, and parents about the causes, symptoms, prevention, and treatment of influenza. The nurse should also teach and demonstrate proper respiratory and hand hygiene practices, such as covering the mouth and nose with a tissue or elbow when coughing or sneezing, disposing of used tissues in a trash can, washing hands frequently with soap and water or using alcohol-based hand sanitizer, avoiding touching the eyes, nose, and mouth, and staying away from sick people.
Choice C reason: Running a mandatory flu clinic is not an appropriate action by the nurse, as it may not be feasible, ethical, or effective in preventing influenza. Influenza vaccination is one of the best ways to prevent influenza and its complications, but it requires informed consent, adequate supply, trained personnel, and appropriate timing. The nurse cannot force or coerce anyone to receive the flu vaccine without their permission or against their wishes. The nurse should respect the autonomy and preferences of the students, staff, and parents, and provide them with evidence-based information about the benefits and risks of influenza vaccination. The nurse should also collaborate with the health department and other community partners to organize voluntary flu clinics that are accessible, affordable, and convenient for those who want to receive the vaccine.
Choice D reason: Closing the school for 6 weeks is not an appropriate action by the nurse, as it may not be necessary, practical, or beneficial in preventing influenza. Influenza outbreaks can vary in severity, duration, and impact depending on several factors, such as the strain of the virus, the level of immunity in the population, the availability of vaccines and antiviral medications, and the implementation of preventive measures. The nurse should monitor the situation closely and follow the guidance of the health authorities regarding school closure decisions. The nurse should also consider the potential consequences of school closure on the student's education, socialization, nutrition, safety, and mental health. The nurse should weigh the benefits and harms of school closure against other alternatives, such as increasing ventilation, cleaning and disinfecting surfaces, screening for symptoms, isolating sick students or staff members, reducing class size or mixing groups.
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.
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