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 D
Explanation
Choice A: Administer corticosteroids. This is incorrect because corticosteroids are used to reduce inflammation and suppress the immune system, but they do not directly affect venous return, stiffness, or muscle strength and endurance.
Choice B: Turn and reposition every 2 hours. This is incorrect because turning and repositioning are important to prevent pressure ulcers and promote circulation, but they are not sufficient to maintain muscle strength and endurance. The client also needs active or passive exercises to prevent muscle atrophy and contractures.
Choice C: Administer interferon. This is incorrect because interferon is a type of immunomodulator that can reduce the frequency and severity of relapses in multiple sclerosis, but it does not directly affect venous return, stiffness, or muscle strength and endurance.
Choice D: Encourage range-of-motion exercises. This is correct because range-of-motion exercises can help increase venous return, prevent stiffness, and maintain muscle strength and endurance in clients with multiple sclerosis. Range-of-motion exercises can be performed actively by the client or passively by the nurse or a caregiver. They should be done at least twice a day to prevent complications such as contractures, spasticity, and pain.
Correct Answer is D
Explanation
Choice A reason: Proactive prevention is not a level of prevention, but rather a type of prevention that involves taking action before a problem occurs or worsens. It can be applied to any level of prevention, such as primary, secondary, or tertiary.
Choice B reason: Secondary prevention is a level of prevention that involves detecting and treating diseases or injuries early before they cause significant complications or disabilities. It includes activities such as screening tests, diagnostic tests, or medications.
Choice C reason: Tertiary prevention is a level of prevention that involves reducing the impact and consequences of diseases or injuries that have already occurred and caused damage or impairment. It includes activities such as rehabilitation, surgery, or palliative care.
Choice D reason: Primary prevention is a level of prevention that involves preventing diseases or injuries from occurring in the first place, by eliminating or reducing risk factors or enhancing protective factors. It includes activities such as immunization, education, or lifestyle modification. Advising a client with osteoporosis to have three servings of milk or dairy products daily is an example of primary prevention because it aims to prevent further bone loss and fractures by increasing calcium intake.
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