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 B
Explanation
Rationale:
A. The person holding financial power of attorney will make health care decisions based on the client's advance directives: A financial power of attorney manages financial matters, not health care decisions. A separate designation such as a health care proxy or medical power of attorney is needed for making medical decisions.
B. The client has the right to refuse medical treatment, even if health care providers recommend it: Under the Patient Self-Determination Act (PSDA), clients have the legal right to make autonomous decisions about their care, including the right to refuse or discontinue treatment, regardless of medical advice.
C. The client's eldest adult child has the right to change advance directives in an end-of-life situation: Advance directives reflect the client’s own decisions. No family member, regardless of birth order, has the legal authority to change them unless specifically authorized as a health care proxy and even then, only if the client is incapacitated.
D. If the client's advance directives are in writing and notarized, the client cannot change it in the future: Clients can revise or revoke advance directives at any time, as long as they remain mentally competent. Notarization does not make the document legally fixed or unchangeable.
Correct Answer is B
Explanation
Rationale:
A. Change the drainage tubing every 48 hr: Closed wound drainage systems are designed to remain intact and sterile until removal. Routine replacement of tubing can introduce pathogens and is not recommended unless there is evidence of damage or contamination.
B. Observe for drainage flow through the tubing: Monitoring the flow and character of drainage ensures the system is functioning correctly and allows early detection of complications like blockage, dislodgment, or infection.
C. Remove the drain if output from the drain increases: An increase in drainage volume can signal active bleeding, infection, or poor wound healing. Instead of removing the drain, the nurse should notify the provider for further evaluation and guidance on next steps.
D. Irrigate the drain to maintain suction: Closed drainage systems like Jackson-Pratt or Hemovac are designed to maintain negative pressure without irrigation. Introducing fluid into the system can break the vacuum seal, reduce effectiveness, and increase the risk of infection.
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