A nurse is field-triaging clients after an industrial accident. Which client condition would the nurse triage with a red tag?

Dislocated right hip and an open fracture of the right lower leg

Large contusion to the forehead and a bloody nose

Closed fracture of the right clavicle and arm numbness

Multiple fractured ribs and shortness of breath

Answer and Explanation

The Correct Answer is D

A. Dislocated right hip and an open fracture of the right lower leg is incorrect for red-tag triage because, while painful and requiring urgent care, these injuries are not immediately life-threatening. This client would typically be triaged as yellow (urgent but can wait a short time for treatment).

B. Large contusion to the forehead and a bloody nose is incorrect because these are minor injuries that are not life-threatening. This client would be triaged with a green tag (delayed, “walking wounded”).

C. Closed fracture of the right clavicle and arm numbness is incorrect because, although this is a concerning injury with possible nerve involvement, it is not immediately life-threatening. This client may also receive a yellow tag.

D. Multiple fractured ribs and shortness of breath is correct because rib fractures combined with respiratory distress indicate a potentially life-threatening condition, such as flail chest or pneumothorax. These conditions can compromise oxygenation and circulation, requiring immediate intervention. In triage, red tags are assigned to clients who need life-saving care without delay.

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Correct Answer is A

Explanation

A. Administer oxygen at 100% per non-rebreather maskis correct because the patient shows signs of hypovolemic shock(cool, clammy skin, tachycardia, hypotension), indicating inadequate tissue perfusion and oxygenation. The first priority in shock is always airway and oxygenationto prevent organ hypoxia and further deterioration. Oxygen administration is immediate and lifesaving.

B. Place the patient on continuous cardiac monitoris important but is secondary. Monitoring helps detect dysrhythmias caused by shock, but it does not directly correct hypoxiaor improve tissue perfusion, which are higher priorities.

C. Draw blood to type and crossmatch for transfusionsis necessary for fluid resuscitation, especially if hemorrhage is suspected, but it is not the first action. Ensuring oxygen delivery to tissues comes before preparing for transfusion.

D. Insert two 14-gauge IV catheters in antecubital spaceis also important for rapid fluid or blood administration, but it comes after oxygen therapy is initiated, since airway and oxygenation take precedence over vascular accessin the initial assessment.

A. "Medication to prevent a gastric ulcer will be administered to my spouse." B. "My spouse will be kept with the head of the bed elevated to about 45 degrees." C. "Sedation will be administered until the ventilator is removed." D. "My spouse will be receiving a low dose anticoagulant as part of the therapy.

Correct Answer is C

Explanation

A. Administering stress ulcer prophylaxis(such as a proton pump inhibitor or H2 blocker) is a component of VAP prevention bundles, as gastric acid suppression reduces the risk of aspiration-related pneumonia. This statement is correct and does not indicate misunderstanding.

B. Elevating the head of the bed 30–45°is a key VAP prevention measure, as it decreases risk of aspiration of gastric contents. This statement demonstrates proper understanding.

C. Continuous deep sedation is not recommendedfor VAP prevention. Over-sedation increases immobility, delays weaning, and increases the risk of VAP. The preferred practice is daily sedation interruption or light sedation, allowing assessment of readiness for weaning and reducing complications. This statement indicates the family needs additional teaching about sedation practices.

D. Low-dose anticoagulation (e.g., heparin) is used for venous thromboembolism (VTE) prophylaxisin mechanically ventilated patients and is part of standard critical care bundles. It does not directly prevent VAP but is appropriate care.

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A nurse is field-triaging clients after an industrial accident. Which client condition would the nurse triage with a red tag?

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Explanation

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Correct Answer is C

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A nurse is field-triaging clients after an industrial accident. Which client condition would the nurse triage with a red tag?