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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Rationale:

A. Instruct the client to have his testosterone checked in 1 week: Testosterone levels are typically monitored after several weeks of therapy, not within just one week. Early testing may not accurately reflect the medication's effectiveness or stability in the bloodstream.

B. Wear clean gloves to apply the gel: Gloves must be worn, but they should be disposable and protective not simply clean gloves. This prevents accidental transdermal absorption of testosterone by the nurse, which can have hormonal effects, especially in females.

C. Apply the gel to the client's genital region: Testosterone gel should not be applied to the genital area due to the risk of irritation and unpredictable absorption. Recommended sites include the shoulders, upper arms, or abdomen where the skin is intact and dry.

D. Advise the client to wait 1 hr before showering or swimming: The client should be instructed to wait at least 1 hour to allow for full absorption of the gel. Showering or swimming too soon can reduce the effectiveness of the medication.

A. Blood pressure B. Urine ketones C. Fetal activity D. Respiratory rate E. Report of headache F. Urine protein G. Gravida/parity

Correct Answer is ["A","C","E","F"]

Explanation

Rationale:

A. Blood pressure: The reading of 162/112 mm Hg meets the criteria for severe hypertension in pregnancy, which increases the risk of complications such as preeclampsia, placental abruption, and stroke.

B. Urine ketones: Ketones are negative, which rules out dehydration or starvation ketosis. Ketones would be more concerning if elevated alongside hyperemesis or gestational diabetes.

C. Fetal activity: Decreased fetal movement at 31 weeks may indicate fetal hypoxia or distress and requires urgent evaluation with nonstress testing or biophysical profiling.

D. Respiratory rate: The client’s respiratory rate of 16/min is within the normal range (12–20/min) and does not indicate respiratory distress or a complication.

E. Report of headache: A severe, persistent headache that is unrelieved by acetaminophen is a classic warning sign of central nervous system involvement in preeclampsia and may precede seizures (eclampsia).

F. Urine protein: The presence of 3+ proteinuria indicates significant renal involvement, supporting a diagnosis of preeclampsia, particularly when paired with hypertension and neurologic symptoms.

G. Gravida/parity: While a history of preterm birth is a known risk factor, her current symptoms point toward preeclampsia rather than complications directly linked to her obstetric history.

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Finding	Nursing Intervention
Client's restlessness	dropdown
Client's behavior towards staff	dropdown
Client's hygiene	dropdown

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is ["A","C","E","F"]

Explanation

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