A nurse in an emergency department is triaging four clients following a mass casualty event.
To which of the clients should the nurse assign a red tag?
A client who has a compromised airway
A client who experienced a brief loss of consciousness
A client who has fixed pupils
A client who has major burns covering 70% of their body
The Correct Answer is A
- A. A client with a compromised airway requires immediate intervention to secure breathing, which is a top priority in triage situations. Without a patent airway, the client is at high risk for suffocation and rapid deterioration.
- B. A client who experienced a brief loss of consciousness may require observation and further assessment, but does not necessarily need immediate life-saving intervention if consciousness has been regained and there are no other signs of airway, breathing, or circulation compromise.
- C. A client with fixed pupils may indicate severe brain injury and, depending on the context, could be considered for a red tag. However, without additional information on breathing and circulation status, it is not the most definitive choice for immediate intervention.
- D. A client with major burns covering 70% of their body is critically injured and will require extensive medical care, but the immediate life-threatening issue in a triage situation is the airway compromise, not the burns themselves.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
A. Hospice care: This option is correct because hospice care provides comprehensive support and comfort measures for terminally ill patients and their families, focusing on improving quality of life in the final stages of an illness.
B. Legal assistance: While legal assistance may be important for advanced care planning and end-of-life decisions, it may not be among the immediate priorities for a client with terminal lung cancer expected to live less than 6 months.
C. Respite care: Respite care allows caregivers to take a temporary break from their caregiving responsibilities, which can be invaluable for family members caring for a terminally ill loved one, providing them with much-needed rest and support.
D. Adult day care: While adult day care may be beneficial for some clients and their caregivers, it may not be as relevant for a client with terminal lung cancer who may have more immediate needs related to symptom management and end-of-life care.
E. Social worker: In this scenario, involving a client with terminal cancer, a social worker can provide emotional support, assist with accessing community resources, and help with care coordination, making this option appropriate.
Correct Answer is B
Explanation
A. While obtaining a replacement is necessary, the immediate priority is ensuring client safety by removing the hazardous equipment first.
B. A frayed electrical cord poses a safety hazard, including the risk of electrical shock, fire, or equipment malfunction. The first priority is to remove the faulty equipment from the client’s environment to prevent potential harm. After removing the IV pump, the nurse should report the issue to the appropriate department, such as engineering or biomedical services, for repair or replacement.
C. This does not directly address the safety risk posed by the frayed cord.
D. While reporting is necessary, the first action should be to remove the unsafe equipment to eliminate immediate danger.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today