A nurse is collecting data for a client during a disaster triage. The client is not breathing, has no carotid or radial pulse, and does not respond to commands. Which of the following color tags should be attached to this client?
Red
Black
Yellow
Green
The Correct Answer is B
A. A red tag indicates clients with life-threatening injuries who have a high chance of survival if they receive immediate treatment. Examples include severe bleeding, airway obstruction, or shock. Since this client has no pulse and is not breathing, they are beyond immediate help, so this tag is inappropriate.
B. A black tag is used for clients who are deceased or expected to die because they show no signs of life (no breathing, no pulse, unresponsive). In mass casualty or disaster triage, resources are prioritized for those with a possibility of survival, so this client would be classified as expectant/deceased and tagged black.
C. A yellow tag designates clients with serious but not immediately life-threatening injuries, such as fractures or controlled bleeding. These clients can wait for treatment after red-tagged individuals are stabilized. This client’s condition is incompatible with life, so yellow is incorrect.
D. A green tag is for clients with minor injuries who can ambulate and wait for care, often called the “walking wounded.” Since this client is unresponsive and pulseless, this is not applicable.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Witnessing the client’s signature on the informed consent form is the nurse’s role, ensuring that the client signed voluntarily and was competent at the time of signing.
B. Obtaining the client’s consent is the responsibility of the provider (surgeon or physician), not the nurse.
C. Describing the consequences of refusing treatment is also the provider’s duty as part of the informed consent process.
D. Explaining the risks and benefits of the procedure must be done by the provider performing the procedure, not by the nurse.
Correct Answer is C
Explanation
A. A living will allows a client to specify preferences for life-sustaining treatments, such as mechanical ventilation or resuscitation, in the event they are unable to communicate their wishes.
B. As long as the client is competent, they can revoke or modify their advance directives or change their designated proxy at any time.
C. This indicates a need for further teaching. Once a client becomes incapacitated, no one can alter their living will—it is a legally binding document that reflects the client’s wishes. Family members must follow the directives as written.
D. The proxy (or durable power of attorney for health care) only becomes active when the client loses decision-making capacity.
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