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: Plantar flexion is the movement of the foot that points the toes downward. It is not a test for gait, but rather a test for muscle strength and nerve function in the lower leg.
Choice B reason: Romberg is a test for balance and coordination that involves asking the client to stand with their feet together and arms at their sides, first with their eyes open and then with their eyes closed. If the client sways or falls when their eyes are closed, it indicates a problem with their proprioception, which is the sense of position and movement of the body. Ataxia is a condition that affects proprioception and causes impaired gait, so Romberg is an appropriate test for it.
Choice C reason: Achilles reflex is the contraction of the calf muscle when the Achilles tendon is tapped. It is not a test for gait, but rather a test for spinal cord function and nerve damage in the lower leg.
Choice D reason: Patellar reflex is the extension of the lower leg when the patellar tendon is tapped. It is not a test for gait, but rather a test for spinal cord function and nerve damage in the upper leg.
Correct Answer is A
Explanation
Choice A reason: Giving the patient extra time to perform activities is an appropriate action by the nurse. Bradykinesia is a symptom of Parkinson's disease that causes slow and reduced movement, making it difficult for the patient to initiate and complete tasks. The nurse should respect the patient's autonomy and dignity, and allow them to do as much as they can by themselves, without rushing or interfering.
Choice B reason: Teaching the client to walk more quickly when ambulating is not an appropriate action by the nurse. Bradykinesia can affect the patient's gait and balance, making them prone to falls and injuries. The nurse should not encourage the patient to walk faster than their ability, but rather provide them with assistive devices, such as a cane or walker, and ensure a safe environment.
Choice C reason: Placing the client on a low-protein, low-calorie diet is not an appropriate action by the nurse. Bradykinesia does not require any specific dietary modifications, unless the patient has other comorbidities, such as diabetes or hypertension. The nurse should ensure that the patient has adequate nutrition and hydration, and avoid foods that may interfere with their medication absorption, such as high-fiber or high-fat foods.
Choice D reason: Completing passive range-of-motion exercises daily is not an appropriate action by the nurse. Bradykinesia can cause muscle stiffness and rigidity, which can limit the patient's range of motion and flexibility. The nurse should encourage the patient to do active range-of-motion exercises, which involve moving their own joints to their full extent, rather than passive ones, which involve someone else moving their joints for them. Active exercises can help maintain muscle strength and joint mobility and prevent contractures and deformities.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today