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
None
None
The Correct Answer is A
A. A compromised airway is an immediate life-threatening condition that requires rapid intervention to ensure oxygenation. In mass casualty triage, this client is tagged red (immediate) because airway issues are often quickly reversible with prompt care.
B. A brief loss of consciousness suggests a possible head injury, but if the client is currently stable, it is not the highest priority. This client would likely receive a yellow tag (delayed).
C. Fixed pupils indicate severe neurological damage and are often associated with a poor prognosis. These clients are typically tagged black (expectant/deceased) rather than red.
D. Burns covering 70% of the body surface area have a very low likelihood of survival, especially in a mass casualty situation. These clients are generally tagged black (expectant) because resources are directed toward those with better chances of survival.
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Related Questions
Correct Answer is D
Explanation
A. The nurse shares their performance plan with another nurse: While sharing the performance plan with another nurse may indicate a level of transparency, it does not necessarily demonstrate that the nurse has improved their performance.
B. The nurse attends a critical thinking class: Attending a class may be part of the remediation plan, but it does not directly indicate whether the nurse's performance has improved.
C. The nurse verbalizes their understanding of the plan: Verbalizing understanding is a positive step, but it does not necessarily guarantee improved performance in practice.
D. The nurse performs all tasks as specified: This is the correct answer. The ultimate goal of a performance improvement plan is to address areas of weakness and ensure that the nurse is able to perform their duties effectively. If the nurse consistently performs all tasks as specified, it
indicates that the plan has been effective in addressing performance issues.
Correct Answer is A
Explanation
A. Black: This tag is used for patients who are deceased or have injuries so severe that survival is unlikely even with immediate medical intervention. Full-thickness burns covering 72% of the body are typically fatal due to the extensive damage to the skin and underlying tissues, high risk of infection, and severe fluid loss.
B. Yellow: This tag is for patients who require observation and whose condition is stable for the moment but who still need hospital care. A patient with such extensive burns would not be stable and would require immediate, intensive care, making this tag inappropriate.
C. Red: This tag is assigned to patients who need immediate treatment to survive. While a patient with extensive burns might initially seem to fit this category, the severity and extent of the burns make survival unlikely even with immediate treatment.
D. Green: This tag is for the "walking wounded" who have minor injuries and do not require urgent care. Clearly, a patient with full-thickness burns over a large portion of their body does not fit this category.
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