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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Correct Answer is ["B","E"]

Explanation

Choice A Reason

Initiate insulin drip. This intervention is not typically included in the standard care plan for all patients with acute pancreatitis. Insulin drips are generally reserved for cases of hypertriglyceridemia-induced pancreatitis, where insulin helps to lower triglyceride levels. For most patients with acute pancreatitis, this is not a standard intervention.

Choice B Reason

Monitor blood glucose levels. This is a correct intervention. Acute pancreatitis can affect the pancreas’ ability to regulate blood sugar, leading to hyperglycemia or hypoglycemia. Monitoring blood glucose levels helps in managing these potential complications and ensuring appropriate treatment.

Choice C Reason

Continue regular diet as tolerated. This statement is incorrect. Patients with acute pancreatitis are usually kept NPO (nothing by mouth) initially to rest the pancreas. Once the inflammation subsides, they may gradually reintroduce oral intake starting with clear liquids and progressing to a low-fat diet.

Choice D Reason

Maintain NPO status until pain-free. This is partially correct but not entirely accurate. While initial management often includes NPO status to rest the pancreas, current guidelines suggest that early enteral feeding can be beneficial and should be started as soon as tolerated. Prolonged NPO status is no longer the standard of care.

Choice E Reason

Manage acute pain. This is a correct intervention. Pain management is a critical component of care for patients with acute pancreatitis. Effective pain control improves patient comfort and can help reduce the stress response associated with severe pain.

A. I should take my medicine with orange juice. B. A bedtime snack will prevent heartburn. C. I will lie down after meals. D. I will limit activities that require bending at the waist.

Correct Answer is D

Explanation

Choice A Reason:

Taking medicine with orange juice is not recommended for clients with GERD. Citrus juices, including orange juice, are highly acidic and can exacerbate GERD symptoms by increasing stomach acidity and causing reflux.

Choice B Reason:

A bedtime snack is likely to worsen heartburn rather than prevent it. Eating close to bedtime can increase the likelihood of acid reflux during the night, as lying down soon after eating can cause stomach contents to flow back into the esophagus.

Choice C Reason:

Lying down after meals is not advisable for clients with GERD. It is recommended to remain upright for at least 2-3 hours after eating to help prevent acid reflux. Lying down can increase the risk of stomach acid flowing back into the esophagus.

Choice D Reason:

Limiting activities that require bending at the waist is a good practice for managing GERD. Bending over can increase abdominal pressure and promote acid reflux. Instead, clients should try to bend at the knees or avoid such activities when possible.

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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 planning care for a client who has acute pancreatitis. Which of the following interventions should the nurse include in the client’s plan? (Select all that apply.)

Correct Answer is ["B","E"]

Explanation

A nurse is providing discharge instructions to a client who has GERD. Which of the following statements by the client demonstrates an understanding of the teaching?

Correct Answer is D

Explanation

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A nurse is caring for a client who is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?

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