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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A nurse withholds nutrition from a client who has a do-not-resuscitate (DNR) order:
Withholding nutrition from a client based solely on a DNR order may not be ethical practice, as nutrition should be provided unless there are specific contraindications or the client has expressed wishes to withhold nutrition.
B. A nurse administers prescribed opioids to a client who has a terminal illness and respiratory rate of 8/min: This is the correct answer. Ethical practice involves providing comfort measures, including appropriate pain management, to clients who are terminally ill and experiencing pain or distress, even if it may inadvertently decrease the respiratory rate.
C. A nurse elects not to care for a client who had an abortion: Refusing to care for a client based on personal beliefs or judgments about their medical history or decisions may not align with ethical practice, as nurses have a professional obligation to provide nonjudgmental care to all clients.
D. A nurse raises all four side rails on the bed of a client who is confused: While ensuring client safety is important, raising all four side rails without considering the client's individual needs and preferences may not be ethical practice, as it may infringe on the client's autonomy and dignity.
Correct Answer is C
Explanation
A. While vital signs may eventually need to be assessed, reorienting the confused and agitated client takes precedence to ensure their safety and well-being.
B. Offering reassurance to the family may be important, but the immediate priority is addressing the client's agitation and confusion.
C. Reorienting the client to their surroundings is the first step in managing confusion and agitation, as it can help ground them and reduce distress.
D. Medicating the client with alprazolam should not be the first action, especially without a proper assessment and consideration of other interventions to address the underlying cause of the agitation.
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