While triaging the wounded from a disaster, you note that one of the wounded is not breathing, radial pulse is absent, capillary refill >2 seconds, and does not respond to your commands. What color tag is assigned?
Green
Yellow
Red
Black
The Correct Answer is D
During triage in a disaster situation, a color tagging system is often used to prioritize and categorize the injured based on the severity of their injuries and the urgency of medical attention required. The colors commonly used in triage are:
● Green tag: Minor injuries that are non-urgent and can typically wait for medical treatment.
● Yellow tag: Injuries that are significant but not immediately life-threatening, requiring medical attention within a few hours.
● Red tag: Critical injuries that are life-threatening but still salvageable with prompt medical intervention.
● Black tag: Injuries that are severe and unsurvivable or incompatible with life. This tag is assigned to individuals who are deceased or have injuries that are beyond the resources available for treatment.
In the given scenario, the absence of breathing, absent radial pulse, prolonged capillary refill, and unresponsiveness indicate a critical condition with no signs of life. Therefore, a black tag would be assigned to this individual.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is E
Explanation
Dependent edema refers to the accumulation of fluid in the dependent parts of the body, which are areas that are most affected by gravity when a person is in a supine or sitting position for an extended period. The sacrum, which is the triangular bone at the base of the spine, is one such dependent area. It is prone to developing edema when there is increased fluid retention in the body, as seen in the patient's weight gain.
To assess for dependent edema accurately, the nurse can gently press the skin over the sacral area with their fingers and observe the skin turgor or the return of the skin to its normal position after releasing the pressure. If there is edema, the skin may have reduced elasticity and take longer to return to its normal position (poor skin turgor).
While edema can occur in other dependent areas such as the feet, ankles, and lower legs, assessing skin turgor in these areas may not provide an accurate determination of dependent edema as they are located further away from the sacrum and may be influenced by other factors.
Correct Answer is D
Explanation
The development of nausea and increased upper abdominal bowel sounds after 24 hours of NG decompression in a patient with gastric outlet obstruction raises concerns for possible complications or changes in the patient's condition. Assessing the patient's vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, can provide important information about their circulatory status and overall stability.
While checking the patency of the NG tube is important, it is not the best immediate action in this situation. The nurse should first assess the patient's vital signs to ensure their stability before proceeding with further interventions.
Placing the patient in a recumbent position (lying down) or encouraging deep breathing and conscious relaxation may not address the underlying issue and could potentially exacerbate the symptoms. It is essential to assess the patient's vital signs and circulatory status to determine the appropriate course of action.
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