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 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.
A client who has an open compound fracture of the humerus.
The Correct Answer is A
Choice A reason: Multiple facial lacerations, if not affecting airway or causing severe bleeding, are minor injuries in triage (green tag). These clients can wait for treatment without immediate risk, aligning with disaster triage principles, making this the correct classification.
Choice B reason: A puncture wound to the lung is life-threatening, potentially causing pneumothorax or hemothorax, requiring urgent intervention (red tag). This is not a minor injury, so it does not qualify for a green tag, making it incorrect.
Choice C reason: Full-thickness burns over the lower extremities are severe, requiring immediate fluid resuscitation and specialized care (red or yellow tag). These are not minor injuries, so this client does not fit green tag criteria, making it incorrect.
Choice D reason: An open compound fracture of the humerus is a significant injury with risks of infection and bleeding, requiring prompt surgical intervention (yellow or red tag). It is not minor, so it does not qualify for a green tag, making it incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A WBC count of 1,300/mm³ indicates severe leukopenia, a contraindication for clozapine due to its risk of agranulocytosis. Low white cells increase infection risk, requiring immediate discontinuation or monitoring per FDA guidelines, making this the critical finding to identify.
Choice B reason: Hemoglobin of 16 g/dL is within normal range (14-18 g/dL) and does not contraindicate clozapine use. Normal hemoglobin supports adequate oxygen transport, so this finding is unremarkable and incorrect for identifying a contraindication.
Choice C reason: Fasting blood glucose of 124 mg/dL indicates mild elevation but is not a contraindication for clozapine, which may worsen glucose control. Monitoring is needed, but this level does not preclude use, making it incorrect.
Choice D reason: Platelet count of 200,000/mm³ is normal (150,000-450,000/mm³) and does not contraindicate clozapine. Normal platelets ensure proper clotting, so this finding is not a concern for clozapine administration, making it incorrect.
Correct Answer is B
Explanation
Choice A reason: Washing hands for 10 seconds with hot water is insufficient; at least 20 seconds with soap and warm water is recommended to remove pathogens post-gardening. Hot water alone is ineffective, so this statement reflects incomplete understanding, making it incorrect.
Choice B reason: Visiting a nephew with chickenpox 5 days after sores crust indicates understanding, as the virus is no longer contagious then. This aligns with CDC guidelines for varicella, protecting the pregnant client and fetus, making it the correct statement.
Choice C reason: Cleaning a cat’s litter box during pregnancy risks toxoplasmosis, which can harm the fetus. Pregnant women should avoid this task, so this statement shows a lack of understanding, making it incorrect for infection prevention.
Choice D reason: Avoiding anyone with a cold sore is overly restrictive, as herpes simplex transmission requires direct contact. General avoidance without context reflects misunderstanding, as precautions like avoiding kissing suffice, making this incorrect.
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