The nurse is assisting in the care of clients during a mass casualty event.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While the provider may need to countersign the prescription, this does not affect the accuracy of the order at the time of receiving it.
B. Verifying the medication name along with its intended purpose helps ensure clarity and reduces the risk of medication errors, especially during telephone orders where miscommunication is more likely.
C. Verbalizing "B-I-D" rather than "twice per day" could cause confusion; clear language is essential, and "twice per day" is more understandable.
D. Using the generic name rather than the trade name is recommended to avoid confusion with similar brand names.
Correct Answer is B
Explanation
A. Assisting a client with counting carbohydrates is important for managing diabetes, but it is not an urgent need that must be addressed immediately.
B. A client with a new tracheostomy who is experiencing coughing episodes may indicate a risk for airway obstruction or other complications, making this the most urgent situation that requires immediate intervention.
C. A client with a BMI of 17 who refuses dinner could be concerning for nutritional status, but it is not as critical as addressing potential airway issues with the tracheostomy client.
D. While demonstrating colostomy care is essential for discharge readiness, it can wait until more urgent needs are addressed. Ensuring the client with a tracheostomy is stable is the priority.
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