A nurse is assisting in performing triage on several clients following a mass casualty event. The nurse should assign a red tag to which of the following clients?
A client who has a sprained left ankle.
A client who has an open traumatic brain injury and agonal breaths.
A client who has sustained a partial amputation of the right leg.
A client who is deceased.
A client who has sustained a major burn to the upper torso and extremities.
The Correct Answer is B
A. A client who has a sprained left ankle is typically categorized as a lower priority in triage.
B. A client who has an open traumatic brain injury and agonal breaths should be assigned a red tag and indicates immediate or emergent care; this client requires immediate attention.
C. A client who has sustained a partial amputation of the right leg requires urgent care but may not be as immediately life-threatening as option B.
D. A client who is deceased typically does not receive further medical intervention in a mass casualty situation.
E. While serious, the severity may not necessitate immediate intervention compared to option B.
F. This is typically categorized as a lower priority in triage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Instructing the client on the use of the call light allows them to easily summon assistance when needed.
B. Applying an ambulation alarm helps monitor the client's movement, especially if there is a risk of falls or wandering.
C. Applying restraints is not the first-line intervention and should only be used when less restrictive measures are ineffective, and the client is at risk of harm to themselves or others.
D. Raising the four side rails of the client’s bed is a safety measure to prevent falls and ensure the client's protection.
E. Checking on the client hourly is an essential intervention to monitor the client’s mental status and ensure safety. Frequent assessments allow for early identification of complications related to opioid use, such as respiratory depression or increased sedation.
Correct Answer is A
Explanation
A. This is because using the same sponge repeatedly can introduce bacteria and other contaminants to the surgical site, increasing the risk of infection.
B. Cleansing the surgical site with a povidone-iodine solution is not recommended because it can cause skin irritation and allergic reactions. The nurse should use a chlorhexidine-based antiseptic solution instead, which is more effective and less toxic.
C. Shaving the client's hair near the surgical site is generally avoided, as it can increase the risk of infection. Hair removal, if needed, is often done with clippers.
D. The surgical site should be scrubbed starting at the center and moving outwards in a circular motion.
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