A nurse is conducting a disaster preparedness drill with a group of nurses who are orienting to the facility. Which of the following triage tag colors should the nurse instruct the group to apply to a client who has full-thickness burns on 72% of his body?

Black

Yellow

Red

Green

Answer and Explanation

The Correct Answer is A

A.   Black tags are typically used for individuals who are deceased or expected to die imminently. The chances of survival for this patient are very minimal since the burn surface area is more than 50% with full thickness burns
B.   Yellow tags are used for those who require observation but are not in immediate danger.
C.   Red tags are for those with severe injuries who require immediate treatment but have a chance of survival.
D.   Green tags are used for individuals with minor injuries or those who require minimal medical assistance.

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Correct Answer is B

Explanation

A: Right-sided flank pain and diaphoresis could indicate a kidney stone or infection, which is painful but not immediately life-threatening.

B: Shortness of breath combined with pain in the neck and shoulder could suggest a myocardial infarction (heart attack), which is a medical emergency requiring immediate attention.

C: Active bleeding from a puncture wound is concerning and requires prompt intervention, but it may not be as immediately life-threatening as a potential heart attack.

D: A raised red skin rash could be a sign of an allergic reaction or infection. While it may require medical attention, it is not as urgent as a potential myocardial infarction.

A. Contact the nurse manager. B. Call risk management to interview the client. C. Reassure the client that the staff is well trained. D. Document in the client's chart that an incident report has been filed.

Correct Answer is A

Explanation

A. Contacting the nurse manager allows for immediate notification of the incident to someone in authority who can initiate appropriate follow-up and investigation.
B. Involving risk management might be necessary but should come after informing the immediate supervisor or manager.
C. Reassuring the client, while important, should not be the primary action; addressing the issue and initiating appropriate steps should take precedence.
D. Documenting the incident report in the client's chart is important but should follow the immediate notification of the supervisor or manager.

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A nurse is conducting a disaster preparedness drill with a group of nurses who are orienting to the facility. Which of the following triage tag colors should the nurse instruct the group to apply to a client who has full-thickness burns on 72% of his body?

Nursing Test Bank

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