A nurse is performing triage on the incident scene for several clients following a mass casualty event. The nurse should assign a red tag to which of the following clients?

A client who has a fractured fibula and tibia

A client who has sustained a major burn to their upper torso and extremities

A client who has a sprained ankle and laceration to the lower leg

A client who has an open traumatic brain injury and agonal breaths

Answer and Explanation

The Correct Answer is D

A. A client who has a fractured fibula and tibia: This is incorrect. While serious, this injury does not require immediate life-saving intervention and is generally categorized as less urgent.
B. A client who has sustained a major burn to their upper torso and extremities: This is incorrect. Although severe, if the client is stable and responsive, they may be categorized as yellow (delayed) unless there are immediate life-threatening complications.
C. A client who has a sprained ankle and laceration to the lower leg: This is incorrect. These injuries are considered less severe and would typically be tagged as green (minor).
D. A client who has an open traumatic brain injury and agonal breaths: This is correct. Agonal breaths and severe head injury indicate a need for immediate life-saving intervention, so this client should receive a red tag for the highest priority.

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Correct Answer is C

Explanation

A. Increased vaginal drainage typically occurs 5 days following surgery: This is incorrect. Vaginal drainage usually decreases over time after surgery, and increased drainage might suggest a complication.
B. Sexual intercourse may be resumed in 1 to 2 weeks: This is incorrect. Sexual activity is generally advised against for 6 weeks or until the healthcare provider confirms it is safe to resume.
C. Artificial lubrication can be used to treat vaginal itching and dryness: This is correct. After a hysterectomy and oophorectomy, vaginal dryness is common due to decreased estrogen levels. Artificial lubrication can help alleviate these symptoms.
D. A Papanicolaou (Pap) test should be performed every 6 months: This is incorrect. After a total abdominal hysterectomy for cancer, Pap tests are generally not required unless there was a history of cervical cancer or other specific indications.

A. Massage the legs. B. Apply dry heat to the legs. C. Elevate the legs. D. Immerse the legs in cold water.

Correct Answer is C

Explanation

A. Massage the legs: This is incorrect. Massage is contraindicated as it can cause further tissue damage and is not appropriate for frostbite.
B. Apply dry heat to the legs: This is incorrect. Dry heat can exacerbate tissue damage. Rewarming should be done using controlled, warm water immersion, not dry heat.
C. Elevate the legs: This is correct. Elevating the legs helps reduce swelling and can prevent further tissue damage. However, rewarming should be done carefully in a controlled environment.
D. Immerse the legs in cold water: This is incorrect. Immersing in cold water would worsen the frostbite. Rewarming should be done using warm (not hot) water, ideally at 37-39°C (98.6-102.2°F), for effective treatment.

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A nurse is performing triage on the incident scene for several clients following a mass casualty event. The nurse should assign a red tag to which of the following clients?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine cancer. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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