A nurse is assisting a charge nurse in triaging clients following a mass casualty event in the community.
Complete the following sentence by using the lists of options.
The nurse should recommend to the charge nurse apply a red tag to
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
A. Client 1 – Expectant/likely to die despite care (black tag)
This client has an open head trauma and is actively dying. In a mass casualty event, resources are directed toward those with the greatest chance of survival. Clients with injuries incompatible with life despite treatment are tagged black (expectant).
B. Client 2 – Life-threatening injury with high possibility of survival (red tag)
The client has a sucking chest wound with severe respiratory distress, tachycardia, hypotension, and hypoxemia (O₂ sat 85%). These are life-threatening injuries that can be rapidly corrected with airway management and wound sealing, giving a high likelihood of survival if treated immediately. Red tag is for immediate care.
C. Client 3 – Minor injuries that can wait (green tag)
This client has an ankle sprain and abrasions-injuries that are not life-threatening and do not require urgent intervention. These are classified as green tag (walking wounded), meaning treatment can be delayed without negative outcomes.
D. Client 4 – Serious injury but can be delayed without risk (yellow tag)
This client has a partial leg amputation with a tourniquet in place, no active bleeding, and stable vital signs for now. The injury is serious but currently controlled, so care can be delayed while higher-priority cases are managed. Yellow tag is for urgent but not immediate cases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Tell the family member to ask the client's provider for access to the client's medical record:
The provider cannot give records without client authorization; the nurse should not direct them to the provider for access without proper consent.
B. Request identification from the family member before providing the information:
Even with ID, family members cannot access medical records without the client’s written consent.
C. Explain that nurses are not allowed to open the medical records of clients not in their care:
Accessing a medical record for a client not under your care is a HIPAA violation unless you have a legitimate, assigned role in their care.
D. Report the situation to the facility's security personnel:
This would be necessary only if the family member posed a threat or attempted to access records unlawfully; the priority is to refuse access and explain privacy rules.
Correct Answer is C
Explanation
A. Admission paperwork:
Admission paperwork is not essential for emergency transfer; it contains historical data that is less urgent for immediate care decisions.
B. Care plan:
While the care plan outlines ongoing interventions, it is less critical for emergency management during an acute event.
C. Medication administration record:
The MAR provides essential, up-to-date information about the client’s current medications, dosages, and administration times, which is critical for safe and accurate care in the receiving facility.
D. Discharge summary:
A discharge summary is completed at the end of a stay, not during an emergency transfer.
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