A nurse is participating in a staff discussion about disaster triage. The nurse should include which of the following clients as an example emergent (red tag) category?

A client who has a punctured femoral artery

A client who has an open fracture

A client who exhibits manifestations of multiple organ failure

A client who has several closed fractures with bruising

Answer and Explanation

The Correct Answer is A

A.   Emergent (red tag) category includes patients with life-threatening injuries requiring immediate attention, such as a punctured femoral artery.
B.   An open fracture may be urgent but not emergent unless associated with severe bleeding or other life-threatening complications.
C.   Manifestations of multiple organ failure are severe but may fall into the expectant (black tag) category.
D.   Closed fractures with bruising may be urgent but not emergent unless there are associated life-threatening complications.

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Correct Answer is B

Explanation

A. Disorientation to place is concerning but may not require immediate reporting.
B. Clear fluid draining from the ear may indicate cerebrospinal fluid leakage, which is a serious concern and requires immediate attention.
C. An elevated heart rate may be a response to the fall and should be monitored but may not require immediate reporting.
D. An edematous bruise on the forehead should be monitored but may not require immediate reporting unless there are signs of more serious injury.

A. Elevate the head of the client’s bed to 45° during meals. B. Instruct the client to tilt their head back while swallowing. C. Turn on the television for the client during meals. D. Provide the client with oral hygiene.

Correct Answer is A

Explanation

A. Elevating the head of the client's bed to 45° during meals helps prevent aspiration by promoting proper swallowing and reducing the risk of food or liquids entering the airway.
B. Instructing the client to tilt their head back while swallowing is not recommended, as it may increase the risk of aspiration.
C. Turning on the television during meals is unrelated to reducing the risk of aspiration pneumonia.
D. Providing the client with oral hygiene is important for overall health but does not specifically address the risk of aspiration pneumonia.

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A nurse is participating in a staff discussion about disaster triage. The nurse should include which of the following clients as an example emergent (red tag) category?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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