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 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.
A client who has an open compound fracture of the humerus.
The Correct Answer is A
Choice A reason: Multiple facial lacerations, if not affecting airway or causing severe bleeding, are minor injuries in triage (green tag). These clients can wait for treatment without immediate risk, aligning with disaster triage principles, making this the correct classification.
Choice B reason: A puncture wound to the lung is life-threatening, potentially causing pneumothorax or hemothorax, requiring urgent intervention (red tag). This is not a minor injury, so it does not qualify for a green tag, making it incorrect.
Choice C reason: Full-thickness burns over the lower extremities are severe, requiring immediate fluid resuscitation and specialized care (red or yellow tag). These are not minor injuries, so this client does not fit green tag criteria, making it incorrect.
Choice D reason: An open compound fracture of the humerus is a significant injury with risks of infection and bleeding, requiring prompt surgical intervention (yellow or red tag). It is not minor, so it does not qualify for a green tag, making it incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Avoiding physical exercise is not recommended for multiple sclerosis, as moderate activity like walking or stretching improves muscle strength, balance, and fatigue management. Complete avoidance leads to deconditioning, worsening mobility and fatigue, which are common in MS, making this instruction counterproductive to symptom management.
Choice B reason: Taking hot baths is not advised for multiple sclerosis, as heat can exacerbate symptoms like fatigue and muscle weakness due to temperature sensitivity (Uhthoff’s phenomenon). Cool or lukewarm baths are safer, supporting symptom control, making this instruction harmful and inappropriate for MS management.
Choice C reason: Performing daily stretching exercises improves flexibility, reduces spasticity, and enhances mobility in multiple sclerosis. Stretching strengthens muscles and prevents contractures, supporting functional independence. This aligns with evidence-based MS management to mitigate symptoms and improve quality of life, making it the correct instruction.
Choice D reason: Limiting fluid intake to reduce bladder irritation is inappropriate, as adequate hydration (2-3 L/day) prevents urinary tract infections, common in MS due to bladder dysfunction. Fluid restriction can worsen symptoms and dehydration, making this instruction incorrect for managing MS-related bladder issues effectively.
Correct Answer is B
Explanation
Choice A reason: A single light fixture along the sidewalk provides limited illumination, insufficient for comprehensive safety. Multiple, evenly spaced lights are needed to prevent falls, especially for older adults. Inadequate lighting increases risks of trips or assaults, indicating the client’s understanding of outdoor safety is incomplete and does not fully address home safety needs.
Choice B reason: Changing smoke alarm batteries annually ensures functional alarms, reducing fire-related mortality by 50%. Regular maintenance supports early smoke detection, enabling timely evacuation or response. This action reflects a strong understanding of fire safety, a critical home safety component, making it the best indicator of the client’s safety awareness.
Choice C reason: A small area rug at the front door poses a tripping hazard, particularly for those with mobility issues. Loose rugs can lead to falls, causing injuries like fractures. This finding suggests the client does not fully understand fall prevention, a key aspect of home safety, making it an incorrect indicator of safety awareness.
Choice D reason: Securing electrical cords under furniture risks fire hazards if cords are damaged or pinched, potentially causing electrical shorts. Cords should be secured along walls or with covers to prevent tripping without compromising safety. This indicates a misunderstanding of electrical safety, increasing fire or injury risks, and is not a correct safety measure.
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