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: This client requires initial teaching, which is typically the responsibility of a registered nurse due to the educational aspect and the need to assess the client's understanding.
- B: Administering an enema is a task that falls within the scope of practice for a licensed practical nurse and does not require the advanced assessment skills of a registered nurse.
- C: Developing an initial plan of care involves comprehensive assessment and critical thinking, which are responsibilities of a registered nurse.
- D: A client transferring from the CCU after a myocardial infarction would require close monitoring and assessment, which are beyond the scope of practice for a licensed practical nurse.

A. "You'll be fine. You'll receive a prescription for pain medication." B. "Why didn't you discuss your concerns with your provider?" C. "If you have the procedure now, you won't have to deal with pain and disability later." D. "I understand, and it's not too late to change your mind,"

Correct Answer is D

Explanation

A. Dismissing the client's concerns and suggesting pain medication without addressing the client's worries isn't an empathetic or helpful response.
B. Asking why the client didn't discuss concerns with the provider might make the client feel guilty or judged for their decision.
C. Pressuring the client by suggesting avoiding future pain and disability isn't respectful of the client's current concerns and decision-making.
D. Acknowledging the client's worries and affirming their ability to change their mind is an appropriate and supportive response.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

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