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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Asking the client's son to go to the waiting area allows the nurse to have a private conversation with the client, which is crucial in suspected cases of elder abuse to gather information without potential interference or intimidation.
B. Asking about injuries with the son present might hinder the client from disclosing information due to fear or pressure.
C. Treating and discharging the client without addressing the suspected elder abuse could potentially put the client in further danger.
D. Filing an incident report might be necessary but should follow an assessment and investigation of the situation.
Correct Answer is B
Explanation
A. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot is not the highest priority because this is a chronic condition that does not pose an
immediate threat to the client's health. The nurse should monitor the client's circulation, provide education on foot care, and encourage smoking cessation if applicable.
B. This client is at risk for urinary retention, which can lead to bladder distension,
infection, and renal damage. The nurse should assess the client's bladder, perform a
bladder scan, and notify the provider if indicated. This is the most urgent situation that requires immediate intervention.
C. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy is not the highest priority because this is a planned procedure that does not require immediate action. The nurse should prepare the client for chemotherapy, provide emotional support, and teach the client about potential side effects and complications.
D. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an
axillary temperature of 38° C (101° F) is not the highest priority because this is a sign of infection that can be managed with antibiotics and infection control measures. The nurse should administer the prescribed antibiotics, monitor the client's vital signs, and
implement contact precautions.
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