A nurse is conducting triage of clients transported from a mass casualty incident (MCI). A client arrives saturated with an unknown substance and medical transport reports feeling dizzy. The nurse should prioritize which actions? SELECT ALL THAT APPLY

Assign the client to a private room

Remove client and transport crew from the Emergency department

Contact decontamination team

Call the scene to identify the chemical

Immediately remove the saturated clothing from the client

Answer and Explanation

Correct Answer : B,C,E

Choice A reason:

Assigning the client to a private room is not the priority action in this scenario. The focus should be on decontamination and preventing the spread of the unknown substance to others in the emergency department. Isolation measures can be considered after initial decontamination.

Choice B reason:

Removing the client and transport crew from the Emergency department is a priority action to prevent contamination of the area and exposure to other patients and staff. This step helps contain the potential hazard and ensures the safety of everyone in the department.

Choice C reason:

Contacting the decontamination team is essential for managing the situation. The decontamination team has the expertise and equipment to safely remove the unknown substance from the client and transport crew, reducing the risk of further exposure and contamination.

Choice D reason:

Calling the scene to identify the chemical can be helpful, but it is not the immediate priority. The focus should be on decontamination and ensuring the safety of the client and others. Identifying the chemical can be done concurrently or after initial decontamination efforts.

Choice E reason:

Immediately removing the saturated clothing from the client is a critical step in the decontamination process. Removing contaminated clothing helps reduce the client’s exposure to the substance and prevents further absorption through the skin.

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Correct Answer is D

Explanation

Choice A reason:

The client’s level of family support is important, but it is not the most critical factor in determining eligibility for Meals-on-Wheels. Family support can supplement the client’s needs, but the primary focus should be on the client’s ability to prepare meals independently.

Choice B reason:

The client’s financial resources are a consideration, but many Meals-on-Wheels programs offer services on a sliding scale or free of charge based on need. Financial resources alone do not determine eligibility; the ability to prepare meals is a more direct indicator of need.

Choice C reason:

The client’s access to transportation is relevant, especially if they need to travel to obtain food. However, Meals-on-Wheels is designed to serve homebound clients who cannot easily leave their homes, making transportation less of a concern compared to the ability to prepare meals.

Choice D reason:

The client’s ability to prepare meals is the most important factor in determining eligibility for Meals-on-Wheels. This program is specifically designed to assist individuals who are unable to prepare nutritious meals for themselves due to physical or cognitive limitations. Ensuring that clients receive adequate nutrition is the primary goal of the program.

A. Red tag B. Black tag C. Green tag D. Yellow tag

Correct Answer is A

Explanation

Choice A: Red tag

A red tag is assigned to patients who require immediate medical attention and intervention to survive. These patients have life-threatening injuries but have a high chance of survival if treated promptly. In this scenario, the client has a respiratory rate of 38, a weak and rapid pulse, and uncontrolled bleeding. These symptoms indicate severe physiological distress and potential shock, necessitating immediate intervention to prevent death. According to NATO triage guidelines, such critical conditions warrant a red tag to prioritize urgent care1.

Choice B: Black tag

A black tag is used for patients who are deceased or have injuries so severe that survival is unlikely even with immediate medical intervention. This category is also known as “expectant” and is used to allocate resources to those with a higher chance of survival. The client in this scenario, despite having severe symptoms, is not described as being beyond the possibility of survival, thus a black tag would not be appropriate 1.

Choice C: Green tag

A green tag is assigned to patients with minor injuries who can wait for medical treatment without immediate risk to life. These patients are often referred to as “walking wounded.” The client’s symptoms of a high respiratory rate, weak and rapid pulse, and uncontrolled bleeding are far too severe to be classified under this category. Assigning a green tag would delay critical care, potentially leading to fatal outcomes1.

Choice D: Yellow tag

A yellow tag is for patients who have serious injuries but whose treatment can be delayed without immediate risk to life. These patients need medical attention but are stable enough to wait for a short period. Given the client’s symptoms, particularly the uncontrolled bleeding and signs of shock, delaying treatment could result in rapid deterioration. Therefore, a yellow tag would not be suitable in this case1.

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A nurse is conducting triage of clients transported from a mass casualty incident (MCI). A client arrives saturated with an unknown substance and medical transport reports feeling dizzy. The nurse should prioritize which actions? SELECT ALL THAT APPLY

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Naxlex Comprehensive Predictor Exams

A nurse is determining if a homebound client is eligible for Meals-on-Wheels. Which of the following is the most important factor for the nurse to consider?

Correct Answer is D

Explanation

A nurse is caring for a client brought to the Emergency Department as one of the first victims of a train accident. The nurse assesses the client, noting a respiratory rate of 38, a weak, rapid pulse, and uncontrolled bleeding. Using NATO guidelines, the nurse assigns which priority tag?

Correct Answer is A

Explanation

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