A nurse is conducting a disaster preparedness drill with a group of nurses who are orienting to the facility. Which of the following triage tag colors should the nurse instruct the group to apply to a client who has full-thickness burns on 72% of his body?

Black

Yellow

Red

Green

Answer and Explanation

The Correct Answer is A

A.   Black tags are typically used for individuals who are deceased or expected to die imminently. The chances of survival for this patient are very minimal since the burn surface area is more than 50% with full thickness burns
B.   Yellow tags are used for those who require observation but are not in immediate danger.
C.   Red tags are for those with severe injuries who require immediate treatment but have a chance of survival.
D.   Green tags are used for individuals with minor injuries or those who require minimal medical assistance.

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Correct Answer is C

Explanation

A. Inadequate food supply is important but might not be the most immediate concern following coronary artery bypass grafting surgery.
B. Limited social support is significant for the client's recovery but might not directly impact the immediate post-operative care.
C. Low pain tolerance after a major surgery like coronary artery bypass grafting can impede recovery, affect mobility, and hinder the client's ability to participate in rehabilitation exercises or manage post-operative pain effectively. Addressing pain
tolerance is crucial for post-operative recovery.
D. Decreased self-esteem, while important for the client's overall well-being, might not be an immediate priority in the early stages following surgery compared to managing physical recovery and pain tolerance.

A. Inform the unit manager of the incident. B. Speak with the AP about the incident. C. Remove the restraints from the client's wrists. D. Review the chart for nonrestraint alternatives for agitation,

Correct Answer is C

Explanation

A. Informing the unit manager is essential but not the first immediate action when a client is improperly restrained.
B. Speaking with the AP about the incident is important, but the priority is to ensure the client's safety and well-being.
C. Removing the restraints from the client's wrists is the first action to address the
inappropriate application of restraints without a prescription to ensure the client's safety and prevent harm.
D. Reviewing the chart for nonrestraint alternatives for agitation is important, but the priority is to address the immediate issue of the improperly applied restraints to the client.

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A nurse is conducting a disaster preparedness drill with a group of nurses who are orienting to the facility. Which of the following triage tag colors should the nurse instruct the group to apply to a client who has full-thickness burns on 72% of his body?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A case manager is preparing a discharge plan for a client following coronary artery bypass grafting surgery. Which of the following client issues should the nurse address first?

Correct Answer is C

Explanation

A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is caring for a client who has cancer. The client's adult child asks the nurse for information about the client's treatment plan. Which of the following responses should the nurse make?

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