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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Instruct the client to change clothing before arriving: This is incorrect. The client should keep the clothing worn during the assault as it may contain crucial evidence.
B. Inform the client that photographs of any injuries will be mandatory for a police report: This is incorrect. While evidence collection is important, it should be done with the client’s consent and consideration of their emotional state.
C. Ask the client to repeat the information obtained during admission: This is incorrect. Asking the client to repeat information can be traumatic. The history should be obtained sensitively and only as needed.
D. Obtain a history of the incident from the client: This is correct. The nurse needs to gather information to provide appropriate care and ensure evidence is collected properly. This should be done in a supportive and respectful manner.
Correct Answer is B
Explanation
A. History of sexually transmitted infection (STI): This is incorrect. A history of STI is not a contraindication for menopausal hormone therapy.
B. History of breast cancer: This is correct. Hormone therapy is not recommended for individuals with a history of breast cancer due to the potential risk of cancer recurrence or progression.
C. History of chronic obstructive pulmonary disease (COPD): This is incorrect. While HT might not be the primary treatment for COPD, it is not contraindicated solely due to COPD.
D. History of thyroiditis: This is incorrect. A history of thyroiditis does not contraindicate the use of hormone therapy for menopause.
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