A nurse is performing triage at the site of a mass casualty. For which of the following clients should the nurse assign a yellow tag?
The client who is experiencing chest pain with radiation to the arm
The client who has a large bruise to the shoulder
The client who is unable to breathe without manual ventilation
The client who has a deep laceration to the leg
The Correct Answer is D
A. Chest pain with radiation to the arm is a potentially life-threatening condition and would likely be tagged red (immediate).
B. A large bruise is considered minor injury and would typically receive a green tag (delayed).
C. A client unable to breathe without manual ventilation requires immediate intervention and would be tagged red (immediate).
D. A deep laceration is serious but not immediately life-threatening; this injury is classified as delayed, warranting a yellow tag.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Respecting and documenting a client’s right to refuse treatment supports their autonomy, a core principle of advocacy.
B. Offering clear, understandable information empowers the client to make informed decisions about their care—an essential part of advocacy.
C. Performing procedures without explanation or consent (even on clients with cognitive impairment) violates advocacy and autonomy. The nurse should attempt to communicate and explain procedures as clearly as possible.
D. Ensuring effective communication through appropriate resources supports the client’s right to understand their care and make informed choices.
E.Client advocacy involves basing care on the client’sgoals and preferences—not solely the nurse’s objectives.
Correct Answer is C
Explanation
A. Pain assessment is a nursing responsibility and involves clinical judgment that cannot be delegated to assistive personnel (AP).
B.This is a sterile procedure requiring nursing knowledge and technique, and must be performed by a licensed nurse.
C. Transporting stable clients is within the scope of practice for assistive personnel, as long as the client does not require ongoing assessment or monitoring during transport.
D. Wound assessment, including measurement, requires clinical evaluation and documentation by a licensed nurse.
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