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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Pouching a client's ostomy bag for a new colostomy requires specialized training and should typically be performed by a nurse.
B. Performing nasal hygiene for a client with an NG tube involves basic hygiene tasks that can be safely delegated to an assistive personnel after proper training and supervision.
C. Measuring oxygen saturation for a client who has dyspnea requires a basic skill that can be delegated to an assistive personnel.
D. Inserting a rectal suppository for a vomiting client involves a nursing task that should be performed by a nurse due to the client's condition and the nature of the task.
Correct Answer is C
Explanation
A. Inadequate food supply is important but might not be the most immediate concern following coronary artery bypass grafting surgery.
B. Limited social support is significant for the client's recovery but might not directly impact the immediate post-operative care.
C. Low pain tolerance after a major surgery like coronary artery bypass grafting can impede recovery, affect mobility, and hinder the client's ability to participate in rehabilitation exercises or manage post-operative pain effectively. Addressing pain
tolerance is crucial for post-operative recovery.
D. Decreased self-esteem, while important for the client's overall well-being, might not be an immediate priority in the early stages following surgery compared to managing physical recovery and pain tolerance.
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