A nurse is triaging a client following a community disaster.
The nurse should identify the client with a Select... –and Select...
Red tag, life-threatening injury requiring immediate intervention
Yellow tag, serious injury requiring delayed but urgent treatment
Green tag, minor injury requiring minimal treatment
Black tag, non-survivable injury with expected poor outcome
The Correct Answer is B
A. Red tag, life-threatening injury requiring immediate intervention: Reserved for clients with compromised airway, severe hemorrhage, or life-threatening injuries requiring immediate treatment. This client is stable, alert, and has no signs of life-threatening conditions.
B. Yellow tag, serious injury requiring delayed but urgent treatment: Applied to clients with significant but non-life-threatening injuries that require medical attention. The client has a large laceration with bleeding and is unable to walk but remains hemodynamically stable, making this the most appropriate classification.
C. Green tag, minor injury requiring minimal treatment: Used for ambulatory clients with minor injuries. The client's inability to walk due to a wound requiring further care excludes them from this category.
D. Black tag, non-survivable injury with expected poor outcome: Assigned to clients with fatal injuries or no signs of life. The client remains alert, oriented, and hemodynamically stable, so this classification is not appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
A. "To harvest a client's organs, they must provide consent prior to death.": Consent can be obtained after death if the individual had previously registered as a donor or if the next of kin provides consent. Organ donation can still occur if the donor has indicated their wishes prior to passing.
B. "The donor client's provider will harvest the organs for donation.": Organ harvesting is typically performed by a specialized team trained in organ procurement, not the primary care provider. The harvesting is conducted by professionals specifically designated for that purpose, ensuring expertise and proper protocols are followed.
C. "During admission, all clients over the age of 18 should be asked about their organ donor status.": It is standard practice to inquire about organ donation status upon admission to ensure that the healthcare team is aware of the client's wishes regarding organ donation. This process helps facilitate informed discussions and planning for potential organ donation.
D. "The National Organ Transplant Act prohibits the sale and purchase of organs.": The Act emphasizes that organ donation should be voluntary and altruistic, making it illegal to buy or sell organs. This law is in place to protect the integrity of the organ donation system and ensure ethical practices.
E. "Documentation about the client's organ donor preference is placed in the electronic medical record.": Documenting the client's organ donor status in their electronic medical record ensures that healthcare providers have access to this important information. It helps to facilitate communication among healthcare providers and supports adherence to the client's wishes.
Correct Answer is B
Explanation
A. Notify the provider: While it is essential to inform the provider about the medication error, the immediate priority is to assess the client's condition first to determine if any adverse effects have occurred. The provider can be notified after ensuring the client is stable.
B. Check the condition of the client: The first action the nurse should take is to assess the client's condition. This includes monitoring for any immediate adverse effects or reactions related to the wrong medication administered. Ensuring the client's safety is the top priority in this situation.
C. Report the occurrence to the unit manager: Reporting the error to the unit manager is an important step in the process but should be done after assessing the client's condition. The immediate focus must be on the client's well-being before addressing administrative aspects of the error.
D. Complete an incident report: Completing an incident report is necessary for documenting the error and ensuring quality improvement measures, but it is not the first action. The nurse must first prioritize the assessment and safety of the client.
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