A nurse is assisting in performing triage on several clients following a mass casualty event. The nurse should assign a red tag to which of the following clients?
A client who has a sprained left ankle.
A client who has an open traumatic brain injury and agonal breaths.
A client who has sustained a partial amputation of the right leg.
A client who is deceased.
A client who has sustained a major burn to the upper torso and extremities.
The Correct Answer is B
A. A client who has a sprained left ankle is typically categorized as a lower priority in triage.
B. A client who has an open traumatic brain injury and agonal breaths should be assigned a red tag and indicates immediate or emergent care; this client requires immediate attention.
C. A client who has sustained a partial amputation of the right leg requires urgent care but may not be as immediately life-threatening as option B.
D. A client who is deceased typically does not receive further medical intervention in a mass casualty situation.
E. While serious, the severity may not necessitate immediate intervention compared to option B.
F. This is typically categorized as a lower priority in triage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Shaking the ampule is not necessary and can create air bubbles in the solution.
B. Snapping the top of the ampule towards the hands is not recommended, as it can cause injury. The top should be snapped away from the nurse.
C. Sterile gloves may be worn for other aspects of the procedure, but it is not necessary to wear them specifically when withdrawing medication from the ampule.
D. Using a filter needle helps prevent glass particles from entering the syringe when withdrawing medication from an ampule.
Correct Answer is C
Explanation
A. Acute pain is more likely to increase respiratory rate, not decrease it.
B. Acute pain does not typically cause hypoglycemia.
C. Acute pain is often associated with an increase in blood pressure (hypertension).
D. Acute pain tends to increase heart rate (tachycardia), not decrease it.
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