A nurse is caring for a client brought to the Emergency Department as one of the first victims of a train accident. The nurse assesses the client, noting a respiratory rate of 38, a weak, rapid pulse, and uncontrolled bleeding. Using NATO guidelines, the nurse assigns which priority tag?

Red tag

Black tag

Green tag

Yellow tag

Answer and Explanation

The Correct Answer is A

Choice A: Red tag

A red tag is assigned to patients who require immediate medical attention and intervention to survive. These patients have life-threatening injuries but have a high chance of survival if treated promptly. In this scenario, the client has a respiratory rate of 38, a weak and rapid pulse, and uncontrolled bleeding. These symptoms indicate severe physiological distress and potential shock, necessitating immediate intervention to prevent death. According to NATO triage guidelines, such critical conditions warrant a red tag to prioritize urgent care1.

Choice B: Black tag

A black tag is used for patients who are deceased or have injuries so severe that survival is unlikely even with immediate medical intervention. This category is also known as “expectant” and is used to allocate resources to those with a higher chance of survival. The client in this scenario, despite having severe symptoms, is not described as being beyond the possibility of survival, thus a black tag would not be appropriate 1.

Choice C: Green tag

A green tag is assigned to patients with minor injuries who can wait for medical treatment without immediate risk to life. These patients are often referred to as “walking wounded.” The client’s symptoms of a high respiratory rate, weak and rapid pulse, and uncontrolled bleeding are far too severe to be classified under this category. Assigning a green tag would delay critical care, potentially leading to fatal outcomes1.

Choice D: Yellow tag

A yellow tag is for patients who have serious injuries but whose treatment can be delayed without immediate risk to life. These patients need medical attention but are stable enough to wait for a short period. Given the client’s symptoms, particularly the uncontrolled bleeding and signs of shock, delaying treatment could result in rapid deterioration. Therefore, a yellow tag would not be suitable in this case1.

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Correct Answer is C

Explanation

Choice A reason:

Developing a survey on teen pregnancies is important for understanding the prevalence and factors contributing to teen pregnancies in the community. However, it is not the most immediate priority intervention. Surveys are useful for data collection but do not provide immediate insights into the overall community health needs.

Choice B reason:

Holding a focus group to discuss immunizations is valuable for gathering community input and addressing concerns about vaccinations. While this is an important public health activity, it is more specific and does not provide a comprehensive overview of the community’s health needs.

Choice C reason:

Performing a windshield survey is a priority intervention for a public health nurse assigned to a new community. This type of survey involves systematically observing the community to gather information about its overall health status, resources, and needs. It provides a broad overview that can inform more targeted interventions and programs.

Choice D reason:

Interviewing the elderly at the senior’s center is important for understanding the specific needs of this population group. However, it is a more focused intervention and does not provide a comprehensive assessment of the entire community’s health needs.

A. Encourage the client to use ice therapy to alleviate muscle stiffness. B. Administer interferon. C. Administer corticosteroids. D. Encourage the client to perform gentle stretching exercises daily.

Correct Answer is D

Explanation

Choice A reason:

Encouraging the client to use ice therapy to alleviate muscle stiffness is not the best approach for managing multiple sclerosis (MS). While ice therapy can provide temporary relief for muscle stiffness, it does not address the need to increase venous return, prevent stiffness, or maintain muscle strength and endurance. Gentle stretching exercises are more effective for these goals.

Choice B reason:

Administering interferon is a common treatment for MS to help reduce the frequency and severity of relapses. However, it does not directly address the need to increase venous return, prevent stiffness, or maintain muscle strength and endurance. Exercise and physical therapy are more appropriate for these specific goals.

Choice C reason:

Administering corticosteroids is used to manage acute exacerbations of MS by reducing inflammation. While corticosteroids can help manage symptoms during a flare-up, they do not directly contribute to increasing venous return, preventing stiffness, or maintaining muscle strength and endurance. Regular exercise is more effective for these purposes.

Choice D reason:

Encouraging the client to perform gentle stretching exercises daily is the most appropriate action. Stretching exercises help increase venous return, prevent stiffness, and maintain muscle strength and endurance. Regular physical activity is essential for managing MS symptoms and improving overall function and quality of life.

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A nurse is caring for a client brought to the Emergency Department as one of the first victims of a train accident. The nurse assesses the client, noting a respiratory rate of 38, a weak, rapid pulse, and uncontrolled bleeding. Using NATO guidelines, the nurse assigns which priority tag?

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Naxlex Comprehensive Predictor Exams

The public health nurse is assigned to the population of clients in an inner-city community. The nurse identifies which of the following as a priority intervention?

Correct Answer is C

Explanation

The nurse is caring for a client with multiple sclerosis. What action does the nurse implement to increase venous return, prevent stiffness, and maintain muscle strength and endurance?

Correct Answer is D

Explanation

The nurse is performing the Romberg test on a client during a neurological assessment. Which of the following best describes the rationale for conducting the Romberg test?

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A nursing preceptor is reviewing life expectancy in the twentieth century with a new nurse. The nurse should recognize that which of the following was most responsible for the dramatic increase in life expectancy during the twentieth century?

A nurse is teaching a client who has a new prescription for Sumatriptan (Imitrex) tablets to treat migraine headaches. Which of the following instructions should the nurse include?

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A nurse is working with a community at risk for flooding. The nurse is aware that identification of at-risk populations, education of the residents about evacuation routes, and emergency shelters is an example of what level of the National Response Framework?

The nurse is providing education to a client who is newly diagnosed with Multiple Sclerosis (MS). Which client statements indicate the need for additional teaching? SELECT ALL THAT APPLY

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