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: The client needs to have someone come in to help her bathe at home is not a data that supports a referral for a social worker, as it is a need for home health care or personal care assistance. The nurse should refer the client to a home health agency or a community resource that provides such services.
Choice B reason: The client needs to arrange financial resources to purchase equipment is a data that supports a referral for a social worker, as it is a need for financial assistance or counseling. The nurse should refer the client to a social worker who can help the client access available resources, such as insurance, grants, or loans, to cover the cost of the equipment.
Choice C reason: The client needs to have someone bring oxygen tanks and equipment to her home is not a data that supports a referral for a social worker, as it is a need for oxygen therapy or equipment delivery. The nurse should refer the client to a respiratory therapist or a durable medical equipment company that can provide the oxygen and the equipment.
Choice D reason: The client needs to have range-of-motion exercises to assist with ambulation is not a data that supports a referral for a social worker, as it is a need for physical therapy or rehabilitation. The nurse should refer the client to a physical therapist or a rehabilitation center that can provide the exercises and the guidance.
Correct Answer is D
Explanation
Choice A reason: Taking pictures of the child's injuries once the parent leaves the room is not a correct action, as it violates the child's privacy and dignity. The nurse should not take pictures of the child without the parent's consent and only if it is required by the facility's policy or the law.
Choice B reason: Having a facility security officer interview the parent is not a correct action, as it is not within the scope of the security officer's role and may escalate the situation. The nurse should not involve the security officer unless there is a threat of violence or harm to the child, the parent, or the staff.
Choice C reason: Completing an incident report concerning the child's injuries is not a correct action, as it is not relevant to the child's situation. The nurse should complete an incident report only if there is an adverse event or error that occurred within the facility that affected the child's care or safety.
Choice D reason: Reporting the child's injuries to Child Protective Services is the correct action, as it is the nurse's legal and ethical duty to protect the child from potential abuse or neglect. The nurse should suspect child abuse based on the child's injuries, which are inconsistent with the parent's explanation and indicative of non-accidental trauma. The nurse should follow the facility's protocol and the state's law for reporting suspected child abuse.
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