A nurse is planning care for four clients who were classified using a disaster triage tag system following a mass casualty event. Which of the following clients should the nurse identify as the priority?

A client who has a green tag

A client who has a yellow tag

A client who has a red tag

A client who has a black tag

Answer and Explanation

The Correct Answer is C

Rationale:
A. A green tag indicates minor injuries; these clients can wait for treatment and are the lowest priority.
B. A yellow tag indicates serious but non-life-threatening injuries; these clients require care soon but are not the highest priority.
C. A red tag indicates life-threatening injuries that require immediate intervention to save the client’s life, making this the highest priority.
D. A black tag indicates deceased or expectant clients whose injuries are so severe that survival is unlikely, and they are the lowest priority for immediate care.

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Correct Answer is B

Explanation

Rationale:
A. A client whose TPN was discontinued and is requesting clear liquids can safely progress diet as prescribed but does not represent an immediate threat to life.
B. Delayed capillary refill after a cardiac catheterization indicates decreased perfusion, possibly from an arterial occlusion or compromised circulation at the insertion site. This is a priority because impaired circulation can lead to limb ischemia and loss if not addressed immediately.
C. Pain management for a postoperative client is important but not life-threatening and can be addressed after circulation is ensured.
D. An oxygen saturation of 90% in a client with COPD may be acceptable, as their baseline oxygen saturation is often lower than average, making this a lesser priority compared to impaired perfusion.

A. A provider uses a nurse's password to access a client's laboratory results. B. A provider leaves a clipboard with the client's vital signs at the client's bedside. C. A nurse posts the schedule for an upcoming x-ray on the whiteboard in the client's room. D. A nurse sends a list of a client's prescribed medications via encrypted email.

Correct Answer is D

Explanation

Rationale:
A. A provider using a nurse’s password violates HIPAA security rules—passwords must never be shared.
B. Leaving a clipboard with vital signs at the bedside risks unauthorized access to personal health information.
C. Posting an x-ray schedule on the client’s whiteboard exposes personal health information to visitors and staff who are not involved in care.
D. Sending client information via encrypted email is a proper method of protecting confidentiality, as it ensures secure transmission of personal health information.

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A nurse is planning care for four clients who were classified using a disaster triage tag system following a mass casualty event. Which of the following clients should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is caring for four clients. Which of the following findings is the highest priority?

Correct Answer is B

Explanation

A nurse manager is teaching a group of nurses about client confidentiality. Which of the following should the nurse manager include as an example of protecting a client's personal health information?

Correct Answer is D

Explanation

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