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.

Nursing Test Bank

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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.

A. Respect the daughter's decision to refuse the transfusion. B. Encourage the daughter to let her mother have the transfusion. C. Discuss taking guardianship of the client with the facility administration. D. Ask the provider to give consent for the transfusion.

Correct Answer is A

Explanation

A. Respecting the daughter's decision to refuse the transfusion aligns with the principles of patient autonomy and the authority granted through the durable power of attorney for health care, meaning the daughter's wishes must be followed.
B. Encouraging the daughter to allow the transfusion would undermine her role as the decision-maker and may cause unnecessary conflict, making this option inappropriate.
C. Discussing guardianship is not necessary or appropriate in this context, as the daughter has already been designated as the decision-maker, which negates the need for additional legal intervention.
D. Asking the provider to give consent for the transfusion contradicts the authority granted to the daughter, as she is the legally recognized decision-maker and has already made her choice.

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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 preparing to perform a dressing change for a client who has a nondraining, stage III pressure ulcer that is infected with methicillin-resistant Staphylococcus aureus (MRSA). Which of the following precautions should the nurse take?

Correct Answer is C

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?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about client confidentiality. Which of the following information should the nurse include?

A nurse is admitting a client for an elective surgical procedure. During the client interview, one of the client's family members faints. Which of the following actions should the nurse take first?

A charge nurse is observing the actions of the facility staff on the unit. Which of the following actions should the charge nurse identify as a possible legal issue?

A nurse notices that a client's health information is visible on an unattended computer screen at the nurses' station. Which of the following actions should the nurse take first?

A nurse is caring for four clients and is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to have the AP perform?

A nurse reviewing prescriptions for a client who has a gastrointestinal bleed is determining the need for special informed consent. Which of the following prescriptions should the nurse identify as covered under the client's general consent for treatment?

A nurse is assisting with the development of an in-service about client advocacy. Which of the following information should the nurse include when describing advocacy?

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?

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.