A nurse is triaging clients injured during a tornado. The nurse assesses a client who has an open fracture of his arm. Which of the following actions should the nurse take?
Perform a rapid head-to-toe assessment.
Place a red tag on the client’s upper body.
Have the client’s wife drive him to the hospital.
Place a yellow tag on the client’s upper body.
The Correct Answer is B
Choice A reason:
Performing a rapid head-to-toe assessment is an essential step in triage, especially in a mass casualty incident like a tornado. However, this action alone does not prioritize the client for immediate treatment. The purpose of triage is to quickly categorize patients based on the severity of their injuries to ensure that those who need urgent care receive it first. While a rapid assessment is necessary, it is not the final step in the triage process.
Choice B reason:
Placing a red tag on the client’s upper body is the correct action. In the triage system, a red tag indicates that the patient has life-threatening injuries that require immediate medical attention. An open fracture, especially in a disaster scenario, poses a high risk of infection and significant blood loss, necessitating urgent care. The red tag helps first responders and medical personnel quickly identify and prioritize this patient for immediate treatment and transport.
Choice C reason:
Having the client’s wife drive him to the hospital is not advisable in a mass casualty situation. This action could delay the client’s access to necessary medical care and potentially worsen his condition. In disaster scenarios, it is crucial to use organized medical transport to ensure that patients receive appropriate care en route to the hospital. Additionally, the client with an open fracture needs stabilization and possibly immediate interventions that cannot be provided in a private vehicle.
Choice D reason:
Placing a yellow tag on the client’s upper body is incorrect. A yellow tag is used for patients who have serious but not immediately life-threatening injuries. These patients require medical attention but can wait a short time for treatment. An open fracture, due to the risk of severe complications, should be prioritized with a red tag. The yellow tag would not appropriately reflect the urgency of the client’s condition.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Drive the client to the nearest emergency department
While it might seem helpful to drive the client to the nearest emergency department, it is not the best course of action. The symptoms described—right-sided weakness and slurred speech—are indicative of a possible stroke. Time is critical in stroke management, and emergency services can provide immediate medical intervention and transport to a stroke center, which is essential for the best possible outcome.
Choice B reason: Call emergency services
Calling emergency services is the most appropriate action. The client is exhibiting signs of a stroke, and rapid medical intervention is crucial. Emergency medical services (EMS) can begin treatment en route to the hospital and ensure the client is taken to a facility equipped to handle strokes. This action maximizes the chances of a positive outcome by minimizing delays in treatment.
Choice C reason: Find a location for the client to sit
Finding a location for the client to sit might provide temporary comfort, but it does not address the urgent need for medical intervention. In the case of a suspected stroke, immediate action is necessary to prevent further damage. Sitting the client down does not provide the critical care needed in this situation.
Choice D reason: Obtain the telephone number of the client’s provider
Obtaining the telephone number of the client’s provider is not the priority in an emergency situation like this. While it might be useful information later, the immediate need is to get the client to a hospital as quickly as possible. Contacting the provider can be done after emergency services have been called.
Correct Answer is D
Explanation
Choice A reason: Bright yellow
Bright yellow urine is typically a sign of normal hydration and is not expected after a transurethral prostatectomy. This color does not indicate the presence of blood or other substances that might be expected following surgery.
Choice B reason: Bright red
Bright red urine indicates significant bleeding, which is not typical after the initial postoperative period. While some blood in the urine is expected immediately after surgery, bright red urine should be reported to a healthcare provider as it may indicate a complication.
Choice C reason: Dark amber
Dark amber urine is usually a sign of dehydration or the presence of bilirubin. It is not typically associated with the expected postoperative changes following a transurethral prostatectomy. This color does not reflect the expected mild bleeding that can occur after the procedure.
Choice D reason: Pale pink
Pale pink urine is expected following a transurethral prostatectomy due to the presence of small amounts of blood in the urine. This is a normal finding as the surgical site heals. The pale pink color indicates mild bleeding, which is common and usually resolves as the healing process continues.
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