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 A

Explanation

Choice A reason: Transporting a school-age client who is in traction to another department is unsafe for a volunteer. Traction involves the use of weights and pulleys to align or immobilize a part of the body, typically after a fracture. This requires careful handling and monitoring to ensure the traction remains effective and does not cause additional injury. Only trained healthcare professionals should manage and transport clients in traction to prevent complications.

Choice B reason: Reading a book to a preschool client who has AIDS is a safe and appropriate assignment for a volunteer. AIDS (Acquired Immunodeficiency Syndrome) is not transmitted through casual contact such as reading a book together. Volunteers can provide emotional support and companionship to children with AIDS without risk of transmission.

Choice C reason: Playing a computer video game with an adolescent who has sickle cell disease is also a safe and suitable activity for a volunteer. Sickle cell disease is a genetic disorder that affects the shape of red blood cells, leading to various complications. However, it is not contagious, and engaging in recreational activities can help improve the adolescent’s quality of life and provide a sense of normalcy.

Choice D reason: Rocking an infant who was admitted for croup is a safe task for a volunteer. Croup is a respiratory condition characterized by a barking cough, often caused by a viral infection. While it can be contagious, the risk of transmission can be minimized with proper hygiene practices. Volunteers can provide comfort and soothing to infants with croup under the supervision of healthcare staff.

A. Why do you think you might have cancer when your diagnosis is a benign condition? B. I’m looking at your chart here and I don’t see any reason for you to worry about that. C. I’m hearing that you are concerned that it might turn out that you have cancer. D. I think that’s something you need to discuss with your provider.

Correct Answer is C

Explanation

Choice A reason: Asking the client why they think they might have cancer when their diagnosis is benign can come across as dismissive and may not address the client’s underlying anxiety. It is important for the nurse to acknowledge the client’s feelings and provide support rather than questioning their concerns.

Choice B reason: Telling the client that there is no reason to worry based on their chart can be seen as dismissive of their feelings. While it may be factually correct, it does not address the client’s emotional state or provide the support they need.

Choice C reason: This response acknowledges the client’s concern and opens the door for further discussion. It shows empathy and understanding, which can help the client feel heard and supported. This approach aligns with therapeutic communication techniques that encourage clients to express their feelings and concerns.

Choice D reason: Suggesting that the client discuss their concerns with their provider is not incorrect, but it may not provide the immediate emotional support the client needs. While it is important for the client to have a detailed discussion with their provider, the nurse should first acknowledge and address the client’s immediate concerns.

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