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. Instructing the AP to request assistance when unsure about a task is important for future situations, but it does not immediately address the current incorrect transfer, which could pose a risk to the client.
B. Demonstrating the proper client transfer technique for the AP directly addresses the immediate issue, ensuring the client is safely transferred and the AP learns the correct method through observation and practice.
C. Helping the AP assist the client with the transfer ensures the client's safety in the moment, but it does not provide the AP with the knowledge or skills needed to perform the task correctly in the future.
D. Referring the AP to the facility procedure manual is useful for long-term learning, but it does not provide the immediate guidance needed to correct the current unsafe transfer.

A. Ask the client's son to go to the waiting area. B. Ask the client about his injuries with the son present. C. Treat and discharge the client. D. File an incident report.

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.

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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 nurse manager observes an assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is assessing an older adult client who was brought to the emergency department by his adult son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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