You're working as a triage nurse during a disaster situation. Based on the triage color code tags placed on each of the wounded, which tag color represents the wounded who has the highest priority of being treated first?
Black
Green
Yellow
Red
The Correct Answer is D
The red tag is used to identify patients with critical injuries who require immediate medical attention. These individuals have life-threatening conditions that, with prompt medical intervention, have a higher chance of survival.
The triage color code system typically follows the following priority order:
1. Red tag: Immediate or emergent care needed for life-threatening injuries or conditions.
2. Yellow tag: Urgent care needed for significant injuries or conditions that are not immediately life-threatening.
3. Green tag: Non-urgent care needed for minor injuries or illnesses that can wait for medical treatment.
4. Black tag: Comfort care or deceased, as the injuries or conditions are incompatible with life or resources are not available for treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E","F"]
Explanation
Ensure the client receives adequate amounts of fluids: This is important to maintain hydration and thin respiratory secretions, making it easier for the client to cough and clear the airways. Check the client's mouth for stomatitis: Methylprednisolone can increase the risk of developing oral candidiasis (thrush) or stomatitis, which can cause discomfort and interfere with oral intake. Regular mouth checks can help identify these conditions early for appropriate management. Assess the client's mental status: Pneumonia, particularly in individuals with pre-existing lung disease like COPD, can lead to hypoxemia, which may affect mental status. It is important to monitor the client's mental status, as changes in cognition or confusion can be indicators of hypoxia and require prompt intervention.
Monitor for signs of hypokalemia: Methylprednisolone, like other corticosteroids, can cause electrolyte imbalances, including hypokalemia (low potassium levels). Hypokalemia can have various effects on the body, including muscle weakness and cardiac dysrhythmias. Regular monitoring of potassium levels and signs of hypokalemia is important for timely management. Monitor the client's blood glucose levels: Methylprednisolone can increase blood glucose levels, particularly in individuals with pre-existing diabetes or impaired glucose tolerance. Regular monitoring of blood glucose levels is necessary to ensure proper glycemic control and prevent hyperglycemia-related complications.
Monitor the client's blood pressure for hypotension: Corticosteroids like methylprednisolone can cause fluid retention, leading to an increase in blood pressure. However, sudden withdrawal of corticosteroids can result in adrenal insufficiency and hypotension. Close monitoring of blood pressure is necessary to identify any significant changes and adjust the medication regimen accordingly.
Correct Answer is C
Explanation
Pancytopenia refers to a decrease in all three major blood cell types: red blood cells (anemia), white blood cells (leukopenia), and platelets (thrombocytopenia). It is a potentially serious side effect that can lead to increased susceptibility to infections, anemia-related symptoms (fatigue, weakness), and an increased risk of bleeding. Prompt reporting is necessary for further
evaluation and appropriate management.
While melena (dark, tarry stools) is a concerning side effect, it typically indicates gastrointestinal bleeding, which should also be reported promptly but may not require immediate action unless the bleeding is severe or accompanied by other symptoms.
Decreased vision can be a side effect of certain medications, including NSAIDs, but it does not usually require immediate reporting unless it is severe or rapidly progressive. Hyperglycemia (high blood sugar) can occur with NSAID therapy, especially in individuals with preexisting diabetes or impaired glucose tolerance. While it should be monitored and managed appropriately, it does not typically require immediate reporting unless it is extremely high or associated with other concerning symptoms.
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