A charge nurse is assisting in triaging clients following a mass casualty event in the community
Complete the following sentence by using the lists of options.
The nurse should apply a red tag to due to
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
In mass casualty triage, clients are categorized using a color-coded tagging system to prioritize care based on the severity of injuries and the likelihood of survival with immediate treatment. The red tag is assigned to clients who have life-threatening but survivable injuries and require immediate medical attention.
Rationale
- Client 1: Open head trauma, actively dying.
➤ This client is in the expectant (black tag) category. Although the injury is critical, the chance of survival is minimal even with treatment. Resources should be conserved for those more likely to survive. - Client 2: Sucking chest wound, difficulty breathing, HR 119, BP 97/65, RR 40, O2 sat 85%.
➤ This client has compromised airway and breathing, and is in respiratory distress but has a chance of survival with immediate intervention (e.g., chest seal, oxygen). This qualifies them for a red tag—immediate priority. - Client 3: Right ankle sprain and leg abrasions.
➤ Minor injuries, stable condition. This client would receive a green tag (walking wounded, delayed care). - Client 4: Partial leg amputation with tourniquet, thready pulse, low BP.
➤ This client is in shock but currently has no active bleeding due to a tourniquet. Though critical, they are more stable than Client 2. They may qualify for a yellow tag (delayed), unless signs of decompensation appear.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While providers have expertise, this statement does not support the client's autonomy or encourage informed decision-making.
B. Suggesting the client talk with family can be helpful, but it still shifts decision-making away from the client’s own preferences.
C. Offering reassurance without information does not support the client’s decision-making process.
D. Providing additional resources empowers the client to make an informed decision and supports autonomy, which is essential in client-centered care.
Correct Answer is A
Explanation
A. The nurse should address the issue directly and immediately by educating the staff about HIPAA regulations and the importance of maintaining client privacy. This promotes accountability and may prevent future breaches.
B.Discussing the incident with another staff nurse is inappropriate and could further violate confidentiality.
C.Reporting to the state board of nursing is a severe action that may be necessary for repeated or egregious violations but is not the first step for a single incident.
D.Filing a grievance report may be warranted if the behavior continues or is serious, but counseling the staff members directly is the appropriate initial response.
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