A triage nurse finds a school-age child lying in the road following a school bus crash with multiple casualties. The child has a respiratory rate of 8/min, is unresponsive to verbal commands, and groans to painful stimuli. The nurse should assign the client which of the following triage tags?

Red

Yellow

Green

Black

Answer and Explanation

The Correct Answer is A

Choice A Reason:

A red tag is used to label those who cannot survive without immediate treatment but who have a chance of survival. The child’s respiratory rate of 8/min, unresponsiveness to verbal commands, and groaning to painful stimuli indicate severe injuries that require urgent medical attention. Immediate intervention is necessary to address potential life-threatening conditions.

Choice B Reason:

A yellow tag is assigned to those who require observation and possible later re-triage. Their condition is stable for the moment, and they are not in immediate danger of death. Given the child’s critical condition, a yellow tag would not be appropriate as it suggests the child can wait for treatment, which is not the case here.

Choice C Reason:

A green tag is for the “walking wounded” who will need medical care at some point after more critical injuries have been treated. This tag is not suitable for the child in question, as their condition is far from minor and requires immediate attention.

Choice D Reason:

A black tag is used for the deceased or those whose injuries are so severe that they are not expected to survive despite receiving care. While the child’s condition is critical, they still have a chance of survival with immediate treatment, making a black tag inappropriate.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A Reason

“You are not contagious when lesions are healed.” This statement is incorrect. Genital herpes can still be contagious even when there are no visible lesions. The virus can be shed from the skin and transmitted to others even in the absence of symptoms.

Choice B Reason

“This infection is spread through the air.” This statement is incorrect. Genital herpes is not spread through the air. It is primarily transmitted through direct skin-to-skin contact, particularly during sexual activity.

Choice C Reason

“Stress can activate an outbreak.” This statement is correct. Stress is a known trigger for reactivation of the herpes simplex virus, leading to outbreaks of genital herpes. Other triggers can include illness, fatigue, and immune suppression.

Choice D Reason

“Antiviral drugs will cure the infection.” This statement is incorrect. While antiviral drugs can help manage symptoms and reduce the frequency of outbreaks, they do not cure the infection. The herpes simplex virus remains in the body and can reactivate.

A. Your provider will use your digital rectal examination to perform the test. B. Your provider will prescribe a stimulant laxative prior to the procedure to evacuate the bowel. C. You should begin annual fecal occult blood testing for colorectal cancer screening at 40 years old. D. You should avoid taking corticosteroids prior to testing.

Correct Answer is D

Explanation

Choice A Reason:

The statement that “Your provider will use your digital rectal examination to perform the test” is incorrect. A fecal occult blood test (FOBT) typically involves collecting stool samples at home over several days, not during a digital rectal examination. The samples are then sent to a lab for analysis to detect hidden blood in the stool.

Choice B Reason:

The statement that “Your provider will prescribe a stimulant laxative prior to the procedure to evacuate the bowel” is also incorrect. There is no need for a stimulant laxative before an FOBT. The test requires normal bowel movements to detect any hidden blood in the stool.

Choice C Reason:

The recommendation to “begin annual fecal occult blood testing for colorectal cancer screening at 40 years old” is not accurate. Current guidelines generally recommend starting colorectal cancer screening at age 45 for individuals at average risk. However, those with higher risk factors may need to start earlier, based on their healthcare provider’s advice.

Choice D Reason:

The statement “You should avoid taking corticosteroids prior to testing” is correct. Certain medications, including corticosteroids, can cause gastrointestinal bleeding, which may lead to false-positive results in an FOBT. Therefore, it is important to avoid these medications before the test, as advised by a healthcare provider.

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A triage nurse finds a school-age child lying in the road following a school bus crash with multiple casualties. The child has a respiratory rate of 8/min, is unresponsive to verbal commands, and groans to painful stimuli. The nurse should assign the client which of the following triage tags?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a new onset of genital herpes. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is teaching a client about fecal occult blood testing (FOBT) for the screening of colorectal cancer. Which of the following statements should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is caring for a client who is using a ventilator when the low-pressure ventilator alarm sounds. Which of the following actions should the nurse take?

A nurse is assessing a client who has had a left-hemisphere stroke. Which of the following findings should the nurse expect?

A nurse is preparing to discharge a client who has a new diagnosis of chronic kidney disease (CKD). Which of the following referrals should the nurse plan to initiate?

A nurse is initiating a plan of care for a client who has COPD. Which of the following interventions should the nurse include?

A nurse is monitoring a client who has a traumatic brain injury and a ventriculostomy drain. The nurse should report which of the following findings as a complication of this therapeutic procedure? (Select all that apply.)

A nurse is admitting a client who has suspected appendicitis. Which of the following findings is the nurse’s priority to report to the provider?

A nurse is teaching a client who has a new diagnosis of polycystic kidney disease. Which of the following statements should the nurse include in the teaching?

A nurse is caring for a client who has active tuberculosis. Which of the following actions should the nurse take?