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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A private room in a quiet location on the unit is the best option for a client in the manic phase of bipolar disorder. This environment minimizes stimulation and distractions, which can help reduce agitation and hyperactivity. It also allows for better control of the client’s environment, which is crucial for managing manic symptoms.
Choice B reason: A private room across from the exercise room is not ideal because the proximity to the exercise room can increase stimulation and noise, potentially exacerbating manic symptoms. Clients in the manic phase need a calm and quiet environment to help stabilize their mood.
Choice C reason: A semi-private room across from the day room is also not suitable. The day room is typically a busy area with a lot of activity and noise, which can be overstimulating for a client in the manic phase. Sharing a room with another client can further increase the risk of agitation and conflict.
Choice D reason: A semi-private room across from the snack area is not recommended for similar reasons. The snack area is likely to have frequent traffic and noise, which can be disruptive. Additionally, sharing a room can lead to increased stimulation and potential conflicts with a roommate.
Correct Answer is B
Explanation
Choice A reason: 90 bpm is the threshold below which the nurse should withhold digoxin for a 6-month-old infant. Digoxin can slow the heart rate, and administering it when the heart rate is already low can increase the risk of bradycardia, a serious heart rhythm disturbance.
Choice B reason: 100 bpm is above the threshold for withholding digoxin in a 6-month-old infant. While it is important to monitor the heart rate, digoxin can be safely administered if the apical heart rate is above 90 bpm.
Choice C reason: 110 bpm is also above the threshold for withholding digoxin. This heart rate indicates that the infant’s heart rate is within a safe range for administering the medication.
Choice D reason: 120 bpm is well above the threshold for withholding digoxin. This heart rate is considered safe for administering the medication, as it indicates the heart rate is not too low.
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