A nurse is collecting data on clients who experienced a disaster. Clients who have the highest priority for being treated first should have which of the following color triage tags?
Black
Yellow
Green
Red
The Correct Answer is D
A. A black tag indicates a client who is deceased or expected to die due to catastrophic injuries. These clients receive comfort measures only, as survival is unlikely even with treatment.
B. A yellow tag is for clients with serious but not life-threatening injuries. Treatment can be delayed without immediate risk of death.
C. A green tag indicates minor injuries (often called “walking wounded”). These clients are stable and can wait for care until more urgent cases are treated.
D. A red tag identifies clients who have life-threatening but potentially survivable injuries that require immediate intervention. These clients are the highest priority during triage, as prompt treatment can significantly improve survival outcomes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is the best example of client advocacy. Advocacy involves protecting and promoting the client’s rights, needs, and preferences, especially when the client cannot effectively speak for themselves. By communicating the client’s wishes to the provider, the nurse ensures that the client’s autonomy and voice are respected in the decision-making process — a core responsibility of advocacy.
B. This action demonstrates fidelity, the ethical principle of keeping commitments and being faithful to professional responsibilities. While important to trust-building, it does not specifically represent advocacy.
C. This is an example of accountability, meaning the nurse acknowledges and answers for their professional behavior and clinical decisions. Accountability reflects professional integrity, not direct advocacy for a client.
D. This describes confidentiality, an ethical and legal obligation to protect a client’s private health information from unauthorized disclosure. It ensures privacy but does not directly involve speaking up or acting on behalf of the client’s needs or wishes.
Correct Answer is D
Explanation
A. The planning step involves developing goals, expected outcomes, and interventions based on the identified nursing diagnoses. It occurs after data collection, not during the initial interview.
B. The diagnosis step requires the nurse to analyze assessment data to identify actual or potential health problems. The nurse cannot make a diagnosis until all relevant information has been gathered.
C. Evaluation occurs after interventions are implemented and focuses on determining whether the client’s goals and outcomes have been met. It does not apply to an initial interview situation.
D. This is the first step of the nursing process, in which the nurse collects and organizes data about the client’s physical, psychological, and social status. Interviewing the client and family to gather information about symptoms, history, and behaviors is part of the assessment phase.
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