A nurse has been assigned to an internal disaster drill team and is triaging clients. Which of the following clients should the nurse classify with a green tag?

A client who has an open compound fracture of the humerus

A client who has multiple facial lacerations

A client who has a puncture wound in the right lower lung

A client who has full-thickness burns over the lower extremities

Answer and Explanation

The Correct Answer is B

Rationale:

A. A client who has an open compound fracture of the humerus: This injury requires surgical intervention and has a moderate to high risk of complications. It is typically classified as yellow, indicating delayed care is acceptable but not minor.

B. A client who has multiple facial lacerations: These are superficial injuries that can be treated with simple wound care and suturing. The client is likely stable and ambulatory, fitting the criteria for a green tag, which denotes minor injuries requiring minimal care.

C. A client who has a puncture wound in the right lower lung: This suggests potential internal injury and respiratory compromise. Such a case is urgent and unstable, requiring immediate intervention, and would be tagged red for immediate treatment.

D. A client who has full-thickness burns over the lower extremities: Full-thickness burns covering a large area are life-threatening and resource-intensive to manage. Depending on the extent, this may fall under red or black, depending on survivability and available resources.

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Correct Answer is D

Explanation

Rationale:

A. Instruct the client to shower and change their clothes: The client should avoid bathing, showering, changing clothes, eating, or drinking before a forensic examination. These actions can destroy vital evidence needed for legal and medical purposes.

B. Ask the client for details about the assault: While the nurse should provide emotional support and allow the client to speak if they choose, probing for details can be retraumatizing. A trained forensic examiner should conduct this interview in a sensitive and structured manner.

C. Reassure the client that their injuries are not life threatening: While reassurance is important, making assumptions about the severity of injuries can invalidate the client’s emotional trauma. The nurse should focus on safety, stabilization, and support.

D. Limit the number of staff members providing care for the client: Reducing the number of caregivers helps minimize overstimulation, preserves privacy, and creates a sense of control and safety for the client. This trauma-informed approach is essential in early post-assault care.

A. Temperature B. Hgb C. Heart rate D. Fundal height

Correct Answer is ["A","C","D","E","F"]

Explanation

Rationale:

A. Temperature: The client's temperature decreased from 38.6°C (101.5°F) to 37.1°C (98.9°F), indicating that the febrile response to infection has resolved. This trend supports the effectiveness of the antibiotic therapy initiated on postpartum day 3.

B. Hgb: Hemoglobin dropped from 11.1 to 10 g/dL, which may reflect continued postpartum blood loss or hemodilution. This decline does not indicate improvement and may require monitoring for worsening anemia.

C. Heart rate; Heart rate improved from 110/min to 78/min, demonstrating reduced physiologic stress and better cardiovascular stability. This aligns with the drop in temperature and suggests systemic recovery from infection.

D. Fundal height; The fundus decreased from 1 cm above the umbilicus to 4 cm below, showing normal postpartum involution. A firm, midline uterus without excessive tenderness also supports clinical improvement.

E. Lochia: Lochia changed from moderate, dark brown, and foul-smelling to a small amount of brownish-red with no odor, which suggests resolving endometrial infection. This progression is typical in healthy postpartum recovery.

F. WBC count: The WBC count normalized from 33,000/mm³ to 10,000/mm³, reflecting resolution of systemic inflammation or infection. This is consistent with decreasing temperature and improved vital signs.

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A nurse has been assigned to an internal disaster drill team and is triaging clients. Which of the following clients should the nurse classify with a green tag?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is ["A","C","D","E","F"]

Explanation

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