Choice A rationale

A sucking chest wound compromises breathing, causes tension pneumothorax, and decreases cardiac output. Hypotension (88/58 mm Hg) and tachycardia (115/min) indicate shock, warranting immediate intervention. Red tag signifies life-threatening but potentially survivable injuries.

Choice B rationale

Penetrating head wounds with irregular breathing suggest brainstem injury, poor prognosis, and impending death. Black tag indicates un-survivable injuries, prioritizing resource allocation to others with a better survival potential.

Choice C rationale

Superficial lacerations involve minor soft tissue damage that does not compromise vital functions. These injuries are non-life-threatening and can wait for delayed medical care without significant risk to life or function.

Choice D rationale

Closed lower leg injuries cause localized pain but do not compromise airway, breathing, or circulation. Pain severity does not indicate life-threatening harm, allowing delayed care. Yellow tag signifies urgent but not immediate need for treatment.

Choice A rationale

Severe but survivable injuries demand immediate care to stabilize critical functions like airway, breathing, and circulation. Prioritizing care ensures better survival outcomes, especially with red tag cases requiring prompt medical intervention.

Choice B rationale

Minor injuries do not threaten life or major functions, so they do not require immediate care. Patients with minor issues are generally green-tagged and can wait without significant adverse outcomes.

Choice C rationale

Non-life-threatening injuries needing follow-up care may have minimal short-term risks, making them less urgent. Such cases often align with yellow tag classifications for priority but non-immediate attention.

Choice D rationale

Injuries without urgent attention lack immediate risk to life or function. These cases can afford to wait without compromising patient outcomes, especially under mass casualty triage protocols.

Choice A rationale

Sucking chest wounds impair oxygenation, posing a direct threat to life. Signs of shock (88/58 mm Hg, heart rate 115/min) demand immediate intervention. Red tag classification reflects life-threatening but treatable conditions needing priority care.

Choice B rationale

Significant penetrating head wounds with irregular breathing indicate brainstem damage, which usually leads to poor outcomes. Black tag assignment denotes expectant management due to un-survivable injuries.

Choice C rationale

Superficial lacerations with stable vitals (118/78 mm Hg) and occlusive dressing in place ensure no life-threatening issues. Green tag indicates minimal care urgency, requiring no immediate intervention.

Choice D rationale

Closed lower leg injuries causing severe pain do not compromise airway, breathing, or circulation. Yellow tag classification reflects delayed medical needs, prioritizing resources for more critical cases.

Choice A rationale

Potassium chloride 20 mEq daily is a common dose for hypokalemia prevention or treatment. Normal serum potassium is 3.5–5.0 mEq/L. This dose is unlikely to cause adverse effects without significant hyperkalemia.

Choice B rationale

Hydrochlorothiazide 25 mg daily effectively manages hypertension by reducing fluid retention. It can cause hypokalemia; thus, monitoring serum potassium is crucial. Normal serum potassium range is 3.5–5.0 mEq/L.

Choice C rationale

Amlodipine 10 mg daily is a standard antihypertensive dose. It is a calcium channel blocker that dilates blood vessels, lowering blood pressure without significant adverse effects in most patients.

Choice D rationale

Clonidine 1 mg TID PRN for systolic blood pressure above 180 is excessive. Normal doses are 0.1–0.3 mg. High doses risk severe hypotension, bradycardia, and withdrawal symptoms. This requires clarification.

Choice A rationale

Administering Albuterol nebulizer 2.5 mg stat is appropriate for acute bronchospasm. Albuterol is a beta-agonist that relaxes airway smooth muscles, improving oxygenation. It is only administered when clinically indicated.

Choice B rationale

Methylprednisolone 50 mg IV is used for severe inflammation. It suppresses immune responses and reduces cytokine activity, but it does not directly address acute symptoms needing immediate intervention.

Choice C rationale

Reassessing vital signs ensures the patient’s stability before administering medications. This is vital in emergencies to evaluate therapy needs and prevent further clinical deterioration.

Choice D rationale

Notifying the provider about worsening symptoms after administration ensures timely interventions. However, preemptive measures, like reassessing stability, take priority before escalation.

Choice A rationale

Cyanotic mucous membranes and oxygen saturation of 84% indicate severe hypoxemia. Normal oxygen saturation is 95–100%. The cyanosis suggests inadequate tissue oxygenation, requiring immediate intervention to prevent respiratory failure.

Choice B rationale

Diffuse wheezing and tremors may signify severe airway obstruction or beta-agonist overuse. While concerning, these findings are not as immediately life-threatening as hypoxemia and cyanosis.

Choice C rationale

Elevated blood pressure (168/90 mm Hg) and heart rate (98/min) may indicate stress or pain but do not reflect acute life-threatening changes compared to severe hypoxemia.

Choice D rationale

Clear rhinorrhea and warm, dry skin may suggest mild upper respiratory infection. These findings do not indicate imminent danger or severe respiratory compromise compared to hypoxemia and cyanosis.

Choice A rationale

Monitoring blood pressure trends ensures early detection of medication effectiveness, yet is secondary to addressing critical hypokalemia. Normal blood pressure is 120/80 mmHg; deviations warrant monitoring, but this is not the priority intervention.

Choice B rationale

Administering potassium chloride STAT addresses potential hypokalemia, which risks arrhythmias and muscle weakness. Normal potassium levels range between 3.5-5.0 mEq/L, highlighting urgency when potassium is below normal.

Choice C rationale

Reassessing additional medication needs at a set time ensures comprehensive care but does not address immediate life-threatening conditions like hypokalemia, which requires urgent correction to prevent cardiac dysfunction.

Choice D rationale

Educating about blood pressure maintenance is crucial for long-term management but does not address the immediate physiological imbalance or risk of arrhythmias due to electrolyte disturbance, making it a lower priority.

Choice A rationale

Washing hands with cold water is less effective for removing pathogens compared to warm water. Warm water opens pores and enhances soap’s efficacy in breaking down oils and debris. Duration is also insufficient.

Choice B rationale

Washing for 10 seconds does not provide sufficient time for thorough microbial removal as evidence supports 15-20 seconds for optimal hand hygiene. Air drying increases the risk of recontamination and bacterial persistence.

Choice C rationale

Using soap and warm water for at least 15 seconds effectively removes microorganisms, reducing cross-infection. Drying with clean paper towels prevents bacterial growth and contamination compared to air drying or reused cloths.

Choice D rationale

Washing with water alone lacks the surfactant action of soap, which emulsifies oils and debris carrying bacteria. Drying with a clean towel prevents contamination but cannot compensate for soap absence.

Choice A rationale

Exercising close to bedtime increases adrenaline and body temperature, which interfere with sleep initiation. Studies recommend ceasing vigorous activity at least 3-4 hours before bedtime to optimize sleep quality.

Choice B rationale

Reducing fluid intake before bed minimizes nocturia, a common sleep disturbance. This aligns with promoting uninterrupted sleep and improving overall sleep hygiene and quality for individuals with insomnia.

Choice C rationale

Taking daytime naps, especially longer than 30 minutes, disrupts circadian rhythms and sleep drive, contributing to difficulty initiating and maintaining sleep during regular hours.

Choice D rationale

Eating a large meal before bedtime delays gastric emptying and may cause discomfort or reflux, both of which interfere with falling asleep. Light snacks are recommended if needed, but not heavy meals.

Choice A rationale

Documenting emesis describes an observed occurrence but does not involve actively performing an intervention, thus representing assessment rather than implementation in client care.

Choice B rationale

Reporting pain as a numeric scale is part of assessment and data collection, not active implementation of nursing interventions aimed at client care.

Choice C rationale

Reporting the absence of nausea or vomiting indicates evaluation of an intervention's effectiveness, which occurs after implementation rather than during it.

Choice D rationale

Contacting the provider actively initiates communication and implementation of interventions, addressing client needs and collaborating with the healthcare team for enhanced care delivery.