A nurse is triaging a client following a community disaster.
The nurse should identify the client with a Select... –and Select...
Red tag, life-threatening injury requiring immediate intervention
Yellow tag, serious injury requiring delayed but urgent treatment
Green tag, minor injury requiring minimal treatment
Black tag, non-survivable injury with expected poor outcome
The Correct Answer is B
A. Red tag, life-threatening injury requiring immediate intervention: Reserved for clients with compromised airway, severe hemorrhage, or life-threatening injuries requiring immediate treatment. This client is stable, alert, and has no signs of life-threatening conditions.
B. Yellow tag, serious injury requiring delayed but urgent treatment: Applied to clients with significant but non-life-threatening injuries that require medical attention. The client has a large laceration with bleeding and is unable to walk but remains hemodynamically stable, making this the most appropriate classification.
C. Green tag, minor injury requiring minimal treatment: Used for ambulatory clients with minor injuries. The client's inability to walk due to a wound requiring further care excludes them from this category.
D. Black tag, non-survivable injury with expected poor outcome: Assigned to clients with fatal injuries or no signs of life. The client remains alert, oriented, and hemodynamically stable, so this classification is not appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Teach the client about the potential health risks of leaving early: The first action the nurse should take is to inform the client about the potential health risks associated with leaving the facility against medical advice. Providing this information ensures that the client is fully informed about the consequences of their decision, which is essential for promoting their safety and well-being.
B. Ask the client to sign a document stating they are leaving AMA: While obtaining a signed document is necessary, it should occur after the client has been informed about the risks involved in leaving. The nurse should first ensure the client understands the implications of their decision.
C. Document the client's statement in direct quotes in the medical record: Documentation is important but should not be the first action taken. The nurse must first address the client’s immediate request and provide information regarding potential health risks before focusing on documentation.
D. Complete an incident report detailing the client scenario: Completing an incident report may be necessary later, but the priority should be to address the client’s safety and ensure they are making an informed decision about leaving the facility. The nurse should first engage with the client regarding their choice and the associated risks.
Correct Answer is A
Explanation
A. "We should start tracking how soon clients are discharged after laparoscopic versus open surgery.": This statement reflects the QSEN concept of quality improvement by focusing on collecting and analyzing data related to patient discharge times. By tracking this information, the team can identify trends, evaluate the effectiveness of care, and implement changes to improve patient outcomes and streamline the discharge process.
B. "We should be sure to log out of the computers immediately following documentation.": While this statement emphasizes an important aspect of safety and confidentiality in documentation, it does not directly address quality improvement initiatives. It focuses more on operational procedures rather than evaluating and enhancing the quality of patient care.
C. "We should involve our clients' partners in care planning as much as possible.": Involving clients' partners in care planning aligns with the QSEN concept of patient-centered care. While this approach is essential for improving patient satisfaction and outcomes, it is not specifically a quality improvement initiative.
D. "We should provide change-of-shift report as a team, including the assistive personnel who assisted with care.": This statement reflects teamwork and communication strategies, which are important for effective patient care. However, it does not directly focus on quality improvement initiatives aimed at evaluating and enhancing the overall quality of care provided to clients.
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