A nurse in an emergency department is triaging four clients following a mass casualty event.

To which of the clients should the nurse assign a red tag?

A client who has a compromised airway

A client who experienced a brief loss of consciousness

A client who has fixed pupils

A client who has major burns covering 70% of their body

Answer and Explanation

The Correct Answer is A

- A. A client with a compromised airway requires immediate intervention to secure breathing, which is a top priority in triage situations. Without a patent airway, the client is at high risk for suffocation and rapid deterioration.
- B. A client who experienced a brief loss of consciousness may require observation and further assessment, but does not necessarily need immediate life-saving intervention if consciousness has been regained and there are no other signs of airway, breathing, or circulation compromise.
- C. A client with fixed pupils may indicate severe brain injury and, depending on the context, could be considered for a red tag. However, without additional information on breathing and circulation status, it is not the most definitive choice for immediate intervention.
- D. A client with major burns covering 70% of their body is critically injured and will require extensive medical care, but the immediate life-threatening issue in a triage situation is the airway compromise, not the burns themselves.

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Correct Answer is B

Explanation

A. Instruct the AP to request assistance when unsure about a task: While this is an important instruction, the immediate priority is ensuring the safety of the client during the transfer.
B. Help the AP assist the client with the transfer: This is the correct answer. The nurse should intervene immediately to ensure the safety of the client during the transfer. Providing assistance to the AP in safely transferring the client is the most appropriate action to take first.
C. Refer the AP to the facility procedure manual: While facility procedures are important, referring to the manual may not address the immediate need to correct the incorrect transfer and ensure client safety.
D. Demonstrate the proper client transfer technique for the AP: While education and demonstration of correct techniques are important, the immediate priority is to intervene and ensure the safety of the client during the transfer.

A. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot B. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38°C (101°F) C. A client who is postoperative following a laminectomy 12 hr ago and is unable to void D. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy

Correct Answer is A

Explanation

A. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot is the highest priority. An absent pedal pulse indicates potential arterial occlusion, which could lead to tissue ischemia and necrosis if not addressed promptly. This situation is critical and requires immediate intervention to restore circulation and prevent permanent damage.

B. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38°C (101°F) is not the highest priority. A mild fever in a client with MRSA indicates infection, but it is not immediately life-threatening. This client needs monitoring and possible adjustment of antibiotics, but the situation does not require urgent intervention.

C. A client who is postoperative following a laminectomy 12 hr ago and is unable to void is concerning, as it could indicate a complication such as urinary retention or spinal nerve damage. However, it is not immediately life-threatening and can be addressed after the more critical issue of a potential arterial occlusion in the client with peripheral vascular disease

D. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy: While this client's diagnosis and treatment plan are significant, they may not require immediate intervention compared to the potential complications of urinary retention in the postoperative client.

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A nurse in an emergency department is triaging four clients following a mass casualty event. To which of the clients should the nurse assign a red tag?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

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A nurse in an emergency department is triaging four clients following a mass casualty event.

To which of the clients should the nurse assign a red tag?