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 C
Explanation
Choice A reason: A provider's prescription is not a resource for developing a standard for removal of indwelling urinary catheters. A prescription is a specific order for a particular client, not a general guideline for a group of clients.
Choice B reason: Maslow's hierarchy of needs is not a resource for developing a standard for removal of indwelling urinary catheters. Maslow's hierarchy of needs is a theory of human motivation that ranks the basic needs of individuals from physiological to self-actualization. It does not provide specific information on how to perform nursing interventions.
Choice C reason: Evidence-based practice is a resource for developing a standard for removal of indwelling urinary catheters. Evidence-based practice is the integration of the best available research evidence, clinical expertise, and client preferences and values into clinical decision making. It helps to ensure that the nursing care is effective, safe, and consistent.
Choice D reason: A critical pathway is not a resource for developing a standard for removal of indwelling urinary catheters. A critical pathway is a tool that outlines the expected course of treatment and outcomes for a specific diagnosis or procedure. It does not provide detailed instructions on how to perform nursing interventions.
Choice E reason: A surgical record is not a resource for developing a standard for removal of indwelling urinary catheters. A surgical record is a document that records the details of a surgical procedure, such as the type of surgery, the anesthesia used, the operative findings, and the complications. It does not provide information on the postoperative care of the client.
Correct Answer is A
Explanation
Choice A reason: This is a correct statement by the newly licensed nurse. Airborne precautions are used for clients who have infections that can be transmitted through the air, such as tuberculosis, chickenpox, or measles. The nurse should have the client wear a mask when leaving the room to prevent spreading the infection to others.
Choice B reason: This is an incorrect statement by the newly licensed nurse. A negative-pressure airflow room is used for clients who are on airborne precautions, not for clients who have compromised immunity. A negative-pressure airflow room prevents contaminated air from escaping the room and infecting others. A client who has compromised immunity should be placed in a positive-pressure airflow room, which prevents outside air from entering the room and exposing the client to pathogens.
Choice C reason: This is an incorrect statement by the newly licensed nurse. An N95 respirator mask is used for clients who are on airborne precautions, not for clients who are on droplet precautions. Droplet precautions are used for clients who have infections that can be transmitted through respiratory droplets, such as influenza, pertussis, or meningitis. The nurse should wear a surgical mask, not an N95 respirator mask, when caring for a client who is on droplet precautions.
Choice D reason: This is an incorrect statement by the newly licensed nurse. Visitors do not need to wear a mask when visiting a client who is on contact precautions, unless they are in direct contact with the client or the client's environment. Contact precautions are used for clients who have infections that can be transmitted through direct or indirect contact, such as MRSA, VRE, or C. difficile. The nurse should wear gloves and a gown, and perform hand hygiene before and after caring for a client who is on contact precautions.
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