A nurse is performing triage on the incident scene for several clients following a mass casualty event. The nurse should assign a red tag to which of the following clients?
A client who has a fractured fibula and tibia
A client who has sustained a major burn to their upper torso and extremities
A client who has a sprained ankle and laceration to the lower leg
A client who has an open traumatic brain injury and agonal breaths
The Correct Answer is D
A. A client who has a fractured fibula and tibia: This is incorrect. While serious, this injury does not require immediate life-saving intervention and is generally categorized as less urgent.
B. A client who has sustained a major burn to their upper torso and extremities: This is incorrect. Although severe, if the client is stable and responsive, they may be categorized as yellow (delayed) unless there are immediate life-threatening complications.
C. A client who has a sprained ankle and laceration to the lower leg: This is incorrect. These injuries are considered less severe and would typically be tagged as green (minor).
D. A client who has an open traumatic brain injury and agonal breaths: This is correct. Agonal breaths and severe head injury indicate a need for immediate life-saving intervention, so this client should receive a red tag for the highest priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Pinch the testicles to feel for abnormalities: This is incorrect. The testicles should be gently palpated, not pinched, to detect abnormalities.
B. Expect swelling of the testicles after examination: This is incorrect. There should be no swelling after a testicular self-examination.
C. Perform testicular self-examination every year: This is incorrect. Self-examination should be performed monthly, not yearly, to detect any changes promptly.
D. Examine the testicles after a bath or shower: This is correct. The warmth and relaxation of the scrotum after a bath or shower make it easier to feel for abnormalities.
Correct Answer is C
Explanation
A. A 28-year-old client who has a history of pelvic inflammatory disease: This is incorrect. While a history of pelvic inflammatory disease does not necessarily contraindicate oral contraceptive use, it should be assessed for any other potential complications or contraindications.
B. A 26-year-old client who is mobile post appendectomy: This is incorrect. Recent surgery, such as an appendectomy, is not a contraindication for oral contraceptives, provided the client is otherwise healthy.
C. A 38-year-old client who reports smoking one pack of cigarettes every day: This is correct. Smoking, especially in women over 35, is a contraindication for oral contraceptives due to the increased risk of cardiovascular events such as thrombosis.
D. A 32-year-old client who has fibrocystic breast disease: This is incorrect. Fibrocystic breast disease does not contraindicate the use of oral contraceptives.
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