The nurse is assisting in the care of clients during a mass casualty event.

Exhibits

For each client, click to specify if the client should be assigned a red, yellow, or black tag. A tag color may be assigned to more than one client.

Client 4

Client 2

Client 1

Client 3

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"}}

Rationale

Client 1: Red tag. This client has a significant loss of blood and a low heart rate, indicating they are in critical condition and need immediate intervention to survive.
Client 2: Yellow tag. This client has second-degree burns and is in pain, but their condition is stable and not immediately life-threatening.
Client 3: Black tag. This client is unresponsive with multiple severe burn injuries and Cheyne-Stokes respirations, indicating a very poor prognosis and unlikely survival.
Client 4: Red tag. This client is experiencing severe chest pain and shortness of breath, which could indicate a life-threatening condition such as a heart attack and requires immediate attention.

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Correct Answer is A

Explanation

A. Waiting 2 minutes between suction passes allows the client to recover and helps to prevent hypoxia, demonstrating an understanding of the suctioning procedure.
B. Wearing clean gloves during suctioning is not appropriate; sterile gloves should be used to prevent introducing pathogens into the airway.
C. The recommended suction pressure for adults is typically between 80 and 120 mm Hg; therefore, setting the suction to 200 mm Hg is too high and could cause trauma to the airway.
D. Suction should be applied only while withdrawing the catheter, not while inserting it, to minimize trauma and prevent oxygen deprivation.

A. Initiate oxygen therapy via nasal cannula for a client who has COPD. B. Initiate a 24-hr urine collection for a client who has end-stage kidney disease. C. Administer an antibiotic for a client who has methicillin-resistant Staphylococcus aureus. D. Change the dressing for a client who has a decubitus ulcer.

Correct Answer is A

Explanation

A. Initiating oxygen therapy for a client with COPD is a priority because oxygenation is critical for clients with respiratory conditions. Hypoxia can lead to serious complications, making this intervention urgent.
B. While initiating a 24-hour urine collection is important for monitoring kidney function, it does not require immediate action compared to the need for oxygen therapy in a client with respiratory distress.
C. Administering antibiotics is essential, especially for a client with an infection like MRSA; however, the need for immediate oxygen therapy takes precedence over medication administration.
D. Changing the dressing for a decubitus ulcer is important for preventing infection and promoting healing but is not as time-sensitive as ensuring adequate oxygenation for the client with COPD.

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The nurse is assisting in the care of clients during a mass casualty event. Exhibits For each client, click to specify if the client should be assigned a red, yellow, or black tag. A tag color may be assigned to more than one client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is supervising a newly licensed nurse who is suctioning a client who has a tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Correct Answer is A

Explanation

A nurse is prioritizing care for four clients. Which of the following tasks should the nurse perform first?

Correct Answer is A

Explanation

A nurse is caring for an older adult client who has advanced dementia and needs a blood transfusion. The client previously designated her adult daughter on a durable power of attorney for health care form, and the daughter refuses the treatment. Which of the following actions should the nurse take?

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A nurse is reinforcing teaching with a group of older adults about collecting home supplies for disaster situations. Which of the following information should the nurse include in the teaching?

A nurse is assisting with the planning of an in-service for a group of newly licensed nurses about transcribing prescriptions from a provider. Which of the following examples should the nurse include as an approved abbreviation?

A nurse enters a client's room and sees smoke coming from a wall outlet. After removing the client from the room, which of the following actions should the nurse take next?

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The nurse is assisting in the care of clients during a mass casualty event.

Exhibits

For each client, click to specify if the client should be assigned a red, yellow, or black tag. A tag color may be assigned to more than one client.