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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Administer pain medication: Pain management is not the primary intervention for exposure to anthrax; the focus should be on addressing the disease directly.
B. Administer antibiotic therapy: This is correct. Post-exposure prophylaxis with antibiotics is crucial in preventing the development of anthrax, especially after exposure to spores.
C. Administer an antiviral medication: This is incorrect. Anthrax is caused by bacteria, not viruses, so antiviral medications are not effective.
D. Administer an antitoxin: While antitoxins are used in treating symptomatic anthrax, the immediate and appropriate action for exposure is to start antibiotic therapy.

A. A client who has acute tonsillitis, is drooling, and has difficulty swallowing B. A client who sustained a deep laceration to their leg and is complaining of dizziness and weakness C. A client who has chronic obstructive pulmonary disease (COPD) with a pulse oximetry reading of 88% D. A client who has lower left abdominal pain and bloody stools

Correct Answer is A

Explanation

A. A client who has acute tonsillitis, is drooling, and has difficulty swallowing: This client is likely experiencing severe swelling or an airway obstruction, which requires immediate attention to ensure the airway is not compromised.
B. A client who sustained a deep laceration to their leg and is complaining of dizziness and weakness: While this client has concerning symptoms, airway compromise is prioritized in triage.
C. A client who has chronic obstructive pulmonary disease (COPD) with a pulse oximetry reading of 88%: This client is hypoxic and requires prompt intervention, but airway issues take precedence.
D. A client who has lower left abdominal pain and bloody stools: This client may have a serious condition but does not require as immediate intervention as a compromised airway.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is working with an emergency response team in caring for a group of people who may have been exposed to anthrax while doing farm work. Which of the following is the most appropriate action for the nurse to take?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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