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 C

Explanation

A. Encouraging the client to talk about his feelings is important, but understanding the client's current perception of his body image comes first to guide appropriate interventions.
B. Discussing coping strategies is relevant, but understanding the client's current perception helps tailor coping strategies to his specific concerns.
C. Determining the client's perception of his body image is the first step to assess the extent of the issue and plan interventions accordingly.
D. Assisting the client to acknowledge a distorted body image may be necessary, but understanding the client's current perception precedes interventions.

A. Lactated Ringer’s B. Dextrose 5% in water C. 0.9% sodium chloride D. Dextrose 5% in 0.9% sodium chloride

Correct Answer is A

Explanation

A. Lactated Ringer’s is the preferred fluid for fluid resuscitation in the first 24 hours after a burn injury as it helps replace lost fluids and electrolytes.
B. Dextrose 5% in water is not the primary fluid for burn resuscitation.
C. 0.9% sodium chloride may be used, but Lactated Ringer’s is often preferred.
D. Dextrose 5% in 0.9% sodium chloride is not the primary fluid for burn resuscitation.

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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

A nurse is contributing to the plan of care for a client who has a disturbed body image following a motor vehicle crash that resulted in a right arm amputation. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is monitoring the fluid replacement of a client who has sustained burns. Which of the following fluids should the nurse use in the first 24 hr following a client’s burn injury?

Correct Answer is A

Explanation

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