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 C
Explanation
The pH value of 7.5 indicates alkalosis, as it is above the normal range of 7.35-7.45. The elevated bicarbonate (HCO3-) level of 34 mmol/L suggests metabolic alkalosis, as it is higher than the normal range of 22-28 mmol/L. The PaCO2 level of 40 mm Hg falls within the normal range of 35-45 mm Hg.
In this case, the primary disturbance is metabolic alkalosis, which is likely caused by the persistent vomiting leading to excessive loss of gastric acid (hydrogen ions) and chloride ions from the stomach. This loss of acid and chloride results in an imbalance of electrolytes and an increase in bicarbonate levels, leading to metabolic alkalosis.
Since there is no significant deviation from the normal range in the PaCO2 level, the respiratory system has not effectively compensated for the metabolic alkalosis. Therefore, it is considered uncompensated.
Correct Answer is C
Explanation
A low-pressure ventilator alarm indicates a potential issue with the delivery of adequate air or pressure from the ventilator. The pulse oximetry reading of 85% suggests that the client is not receiving sufficient oxygenation.
Providing ventilation with a bag-valve-mask device allows the nurse to manually assist the client's breathing and ensure proper oxygenation and ventilation while troubleshooting the ventilator alarm. By manually ventilating the client, the nurse can help maintain oxygenation and prevent further hypoxemia until the underlying cause of the alarm can be identified and resolved.
Suctioning the client's endotracheal tube, adding air to the pilot balloon, or placing a bit block in the client's mouth may be appropriate interventions in specific situations, but they are not the immediate priority in this case. The primary concern is to address the low oxygen saturation and ensure adequate ventilation.
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