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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.

A.

Client 4

B.

Client 2

C.

Client 1

D.

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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Related Questions

Correct Answer is A

Explanation

A. Reporting the concern to the charge nurse is the appropriate action, as it ensures that the issue is addressed through proper channels. The charge nurse can investigate and determine if further action is needed, such as reviewing the medication administration process.
B. Questioning the nurse directly could lead to confrontations and is not the correct procedure for handling potential discrepancies in medication administration.
C. Notifying the pharmacy is unnecessary at this point because the issue concerns administration rather than medication supply or errors with the prescription.
D. While documenting the client’s report is important, simply documenting the client’s claim without notifying the charge nurse does not fully address the concern.

Correct Answer is C

Explanation

A. Wearing protective eyewear is not typically required for dressing changes unless there is a risk of splashing or spraying of fluids.
B. A mask is not necessary for dressing changes unless there is a risk of respiratory droplet transmission, which is not applicable in this situation.
C. Using dedicated equipment for the client is crucial to prevent the spread of MRSA and ensure infection control.
D. Turning on the HEPA filtration system is not a standard practice for dressing changes and does not specifically address the infection control needs of the client with MRSA.

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