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 A
Explanation
Choice A reason: This is the correct choice because this client has the least urgent and most stable condition. A deep-vein thrombosis is a blood clot that forms in a vein, usually in the leg. An INR of 2.0 indicates that the client's blood is within the therapeutic range for anticoagulation therapy, which prevents the clot from growing or breaking off. The nurse should ensure that the client has a prescription for oral anticoagulants, compression stockings, and follow-up appointments before discharging them.
Choice B reason: This is not the correct choice because this client has a serious and potentially life-threatening condition. Tumor lysis syndrome is a complication of chemotherapy that occurs when cancer cells break down rapidly and release their contents into the bloodstream. This can cause electrolyte imbalances, kidney damage, and cardiac arrhythmias. The nurse should monitor the client's vital signs, laboratory values, urine output, and fluid balance, and administer medications and interventions as prescribed.
Choice C reason: This is not the correct choice because this client has a new and acute condition. A new onset of left-sided weakness could indicate a stroke, which is a medical emergency that requires immediate diagnosis and treatment. The nurse should perform a neurological assessment, check the client's blood pressure and blood glucose levels, and activate the stroke protocol.
Choice D reason: This is not the correct choice because this client has a severe and unstable condition. Angina is chest pain that occurs when the heart muscle does not get enough oxygen-rich blood. A troponin level of 3 ng/mL indicates that the client has a high level of cardiac enzymes in the blood, which suggests a heart attack or myocardial infarction. The nurse should administer oxygen, nitroglycerin, aspirin, and morphine as prescribed, and prepare the client for further diagnostic tests and interventions.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because a social worker can help the parent with financial assistance, insurance coverage, or other resources to obtain the nebulizer and the medication for the child. A social worker can also provide emotional support and education to the parent and the child about asthma management.
Choice B reason: This is not the correct choice because a pharmacist can only provide information about the medication, such as the dosage, side effects, and interactions. A pharmacist cannot help the parent with the cost of the nebulizer or the medication.
Choice C reason: This is not the correct choice because child protective services is not a referral that the nurse should recommend in this situation. The parent is not neglecting or abusing the child, but rather expressing a concern about the affordability of the nebulizer. Reporting the parent to child protective services could cause more harm than good to the parent-child relationship and the child's well-being.
Choice D reason: This is not the correct choice because a respiratory therapist can only provide technical assistance and education on how to use the nebulizer and the medication. A respiratory therapist cannot help the parent with the cost of the nebulizer or the medication.
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