A nurse in the emergency department is assessing clients who have been triaged using the triage tag system following a hurricane disaster. Which of the following clients should the nurse assess first?
A client who has a red tag
A client who has a green tag
A client who has a yellow tag
A client who has a black tag
The Correct Answer is A
Choice A reason: A client who has a red tag is the first priority for the nurse, as it indicates that the client has life-threatening injuries that require immediate attention and treatment. The nurse should assess and stabilize the client as soon as possible.
Choice B reason: A client who has a green tag is the last priority for the nurse, as it indicates that the client has minor injuries that do not require urgent care. The nurse should assess and treat the client after all other clients have been attended to.
Choice C reason: A client who has a yellow tag is the second priority for the nurse, as it indicates that the client has serious injuries that require timely care but can wait for a short period of time. The nurse should assess and treat the client after the red-tagged clients have been stabilized.
Choice D reason: A client who has a black tag is not a priority for the nurse, as it indicates that the client is deceased or has fatal injuries that are beyond the scope of care. The nurse should not attempt to resuscitate or treat the client, but rather focus on the clients who have a chance of survival.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Allowing the AP to document the vital signs prior to logging out is not a correct action, as it violates the principles of confidentiality and accountability. The nurse should not share their login credentials or allow anyone else to use their electronic record.
Choice B reason: Logging out so the AP can log in to document the vital signs is the correct action, as it ensures that the documentation is accurate, timely, and secure. The nurse should log out of the electronic record after completing their charting and allow the AP to log in using their own credentials.
Choice C reason: Offering to chart the vital signs for the AP is not a correct action, as it delays the documentation and increases the risk of errors. The nurse should not chart the vital signs for the AP, as they are not the ones who obtained them.
Choice D reason: Recommending the AP come back later when the record is available is not a correct action, as it also delays the documentation and reduces the availability of the electronic record. The nurse should not make the AP wait for the record, as it may affect the continuity of care.
Correct Answer is C
Explanation
Choice A reason: Using condoms during treatment for chlamydia is important for preventing transmission, but this is not the priority nursing action. The most critical step for the nurse is fulfilling the legal and public health obligation to report the infection to the health department, as chlamydia is a reportable sexually transmitted infection.
Choice B reason: This is not the correct choice because this action is not appropriate for clients who have chlamydia. Chlamydia is caused by bacteria, not viruses, so antiviral creams are ineffective and unnecessary. The nurse should administer the prescribed antibiotics and monitor the client for any adverse reactions or complications.
Choice C reason:Reporting the infection to the local health department is correct. Chlamydia is a reportable disease in all states, and this step ensures proper public health tracking, partner notification, and prevention of further spread. This is a nurse’s responsibility in accordance with infection control and community health regulations.
Choice D reason: This is not the correct choice because this action is not indicated for clients who have chlamydia. Contact precautions are used to prevent the transmission of infections that are spread by direct or indirect contact with the client or their environment. Chlamydia is not spread by contact, but by sexual intercourse. The nurse should use standard precautions, which include hand hygiene and wearing gloves, when caring for the client.
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