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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A reason:

The statement “Dark urine” is not typically a manifestation of an allergic reaction to oxacillin. Dark urine can indicate other issues such as dehydration, liver problems, or the presence of blood, but it is not a common sign of an allergic reaction to antibiotics.

Choice B reason:

The statement “Diarrhea” is a common side effect of many antibiotics, including oxacillin, but it is not specifically indicative of an allergic reaction. Diarrhea can occur due to the disruption of normal gut flora by antibiotics, but it does not necessarily mean the patient is allergic to the medication.

Choice C reason:

The statement “Urticaria” (hives) is a classic sign of an allergic reaction. Urticaria presents as raised, itchy welts on the skin and is a common allergic response to medications, including oxacillin. This reaction occurs when the immune system releases histamines in response to the drug.

Choice D reason:

The statement “Fever” can be associated with both infections and allergic reactions, but it is not a definitive sign of an allergic reaction to oxacillin. Fever can occur due to the underlying infection being treated or as a side effect of the medication, but it is not as specific as urticaria for indicating an allergic response.

A. Provide bedtime rituals. B. Encourage play exercises in the evening. C. Explain the source of the toddler’s fears. D. Turn off the room light.

Correct Answer is A

Explanation

Choice A reason:

The statement “Provide bedtime rituals” is correct. Establishing a consistent bedtime routine can help toddlers feel more secure and relaxed, which can promote better sleep. Bedtime rituals might include reading a story, singing a lullaby, or having a warm bath before bed. These activities signal to the child that it is time to wind down and prepare for sleep.

Choice B reason:

The statement “Encourage play exercises in the evening” is incorrect. While physical activity is important for overall health, engaging in stimulating play exercises right before bedtime can make it harder for toddlers to settle down and fall asleep. It is better to encourage quiet, calming activities in the evening.

Choice C reason:

The statement “Explain the source of the toddler’s fears” is not the most effective approach for promoting sleep. While addressing fears is important, the explanation alone may not be sufficient to help the toddler feel secure enough to sleep. Providing comfort and reassurance through bedtime rituals is more effective in creating a sense of safety.

Choice D reason:

The statement “Turn off the room light” is partially correct but not the best standalone solution. While a dark environment can promote sleep, some toddlers may feel more secure with a nightlight. The focus should be on creating a calming and comfortable sleep environment, which includes but is not limited to adjusting the lighting.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is taking oxacillin to treat an infection. The nurse should recognize which of the following findings is a manifestation of an allergic reaction?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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