A nurse has been assigned to an internal disaster drill team and is triaging clients. Which of the following clients should the nurse classify with a green tag?
A client who has an open compound fracture of the humerus
A client who has multiple facial lacerations
A client who has a puncture wound in the right lower lung
A client who has full-thickness burns over the lower extremities
The Correct Answer is B
Rationale:
A. A client who has an open compound fracture of the humerus: This injury requires surgical intervention and has a moderate to high risk of complications. It is typically classified as yellow, indicating delayed care is acceptable but not minor.
B. A client who has multiple facial lacerations: These are superficial injuries that can be treated with simple wound care and suturing. The client is likely stable and ambulatory, fitting the criteria for a green tag, which denotes minor injuries requiring minimal care.
C. A client who has a puncture wound in the right lower lung: This suggests potential internal injury and respiratory compromise. Such a case is urgent and unstable, requiring immediate intervention, and would be tagged red for immediate treatment.
D. A client who has full-thickness burns over the lower extremities: Full-thickness burns covering a large area are life-threatening and resource-intensive to manage. Depending on the extent, this may fall under red or black, depending on survivability and available resources.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. "Begin each feeding using the same breast.": It's recommended to alternate breasts between feedings to ensure both breasts are emptied regularly. This helps maintain milk production and prevents engorgement or blocked ducts.
B. "Supplement breastfeedings with water every 12 hours.": Newborns do not require supplemental water. Breast milk provides all the necessary hydration and nutrients for the infant’s needs, even in hot weather.
C. "Offer your infant the breast when he shows signs of hunger.": Feeding on demand based on hunger cues—such as rooting, sucking motions, or hand-to-mouth activity—supports adequate nutrition, growth, and milk supply.
D. "Limit the time your infant feeds to 10 minutes on each breast.": Feeding should not be time-restricted. Infants should be allowed to feed until they are satisfied, as some may take longer to extract enough milk, especially in the early weeks.
Correct Answer is C
Explanation
Rationale:
A. "Maintain the client in a supine position for 24 hours following surgery.": Prolonged supine positioning increases the risk of pulmonary complications such as atelectasis. Early mobilization and elevating the head of the bed help promote lung expansion and reduce postoperative risks.
B. "Expect the client to have a palpable distended bladder following surgery.": A distended bladder is not expected and may indicate urinary retention, a common complication after anesthesia. The nurse should assess and address it promptly, rather than consider it normal.
C. "Report bleeding that saturates the client's dressing.": Active bleeding that saturates a postoperative dressing may indicate hemorrhage and requires immediate intervention. Reporting this finding is critical to prevent further complications like hypovolemia or shock.
D. "Ensure the client's urinary output is no less than 20 mL per hour.": Urine output should be at least 30 mL per hour in adults. A rate below this may indicate hypoperfusion or renal impairment and should prompt further assessment and intervention.
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