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. Supporting a client’s wishes to refuse prescribed treatments demonstrates autonomy, which is the ethical principle that respects a client’s right to make their own informed decisions about their care.
B. Ensuring that a client understands expectations for group participation reflects veracity or providing clear information, but does not directly demonstrate autonomy.
C. Describing the adverse effects of medications is part of informed consent and education, supporting autonomy indirectly, but the primary action is information provision.
D. Spending extra time to calm an agitated client reflects beneficence and caring, focusing on the client’s well-being rather than decision-making rights.
Correct Answer is B
Explanation
A. This task involves assessment, sterile technique, and evaluation of tissue healing—all of which require nursing knowledge and clinical judgment. Therefore, it cannot be delegated to an assistive personnel (AP).
B. This is an appropriate task to delegate to an AP because it is routine, predictable, and noninvasive. It does not require assessment or decision-making. The AP can collect the data, while the nurse interprets the results and determines any necessary actions related to fluid balance and cardiac function.
C. Medication administration requires a licensed nurse who can assess pain, evaluate effectiveness, and monitor for side effects. This task is outside the scope of practice for an AP.
D. Even though reinforcement sounds simple, it still involves teaching and evaluation of understanding, which are nursing responsibilities. The nurse must ensure the client demonstrates proper technique and compliance, so this task cannot be delegated to an AP.
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