A nurse is triaging clients injured during a tornado. The nurse assesses a client who has an open fracture of his arm. Which of the following actions should the nurse take?
Perform a rapid head-to-toe assessment.
Place a red tag on the client’s upper body.
Have the client’s wife drive him to the hospital.
Place a yellow tag on the client’s upper body.
The Correct Answer is B
Choice A reason:
Performing a rapid head-to-toe assessment is an essential step in triage, especially in a mass casualty incident like a tornado. However, this action alone does not prioritize the client for immediate treatment. The purpose of triage is to quickly categorize patients based on the severity of their injuries to ensure that those who need urgent care receive it first. While a rapid assessment is necessary, it is not the final step in the triage process.
Choice B reason:
Placing a red tag on the client’s upper body is the correct action. In the triage system, a red tag indicates that the patient has life-threatening injuries that require immediate medical attention. An open fracture, especially in a disaster scenario, poses a high risk of infection and significant blood loss, necessitating urgent care. The red tag helps first responders and medical personnel quickly identify and prioritize this patient for immediate treatment and transport.
Choice C reason:
Having the client’s wife drive him to the hospital is not advisable in a mass casualty situation. This action could delay the client’s access to necessary medical care and potentially worsen his condition. In disaster scenarios, it is crucial to use organized medical transport to ensure that patients receive appropriate care en route to the hospital. Additionally, the client with an open fracture needs stabilization and possibly immediate interventions that cannot be provided in a private vehicle.
Choice D reason:
Placing a yellow tag on the client’s upper body is incorrect. A yellow tag is used for patients who have serious but not immediately life-threatening injuries. These patients require medical attention but can wait a short time for treatment. An open fracture, due to the risk of severe complications, should be prioritized with a red tag. The yellow tag would not appropriately reflect the urgency of the client’s condition.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Assisting the client on a bedpan to urinate can help if the bladder is full, as a full bladder can impede uterine contraction and contribute to bleeding. However, this is not the immediate priority. The primary concern is to control the bleeding, which requires more direct intervention.
Choice B reason:
Increasing the client’s fluid intake is important for maintaining hydration, especially if there is significant blood loss. However, this action does not directly address the cause of the bleeding. Immediate measures to control the hemorrhage are more critical.
Choice C reason:
Palpating the client’s uterine fundus is an essential step in assessing the cause of the bleeding. If the uterus is not contracting properly (uterine atony), it can lead to excessive bleeding. However, while this assessment is crucial, it is not the definitive intervention to stop the bleeding.
Choice D reason:
Preparing to administer oxytocic medication is the priority intervention. Oxytocic drugs, such as oxytocin (Pitocin), stimulate uterine contractions, which help to control and reduce postpartum hemorrhage. Administering this medication promptly can effectively manage the bleeding and prevent further complications.
Correct Answer is A
Explanation
Choice A reason:
The statement “Fetal position is persistent occiput posterior” is correct. The occiput posterior (OP) position is when the baby’s head is down but facing the mother’s abdomen. This position can cause prolonged labor and severe backache because the baby’s head is not optimally aligned with the birth canal, making it harder for the baby to descend. The OP position often leads to more painful and prolonged labor, and it is associated with a higher likelihood of interventions such as forceps or vacuum delivery, or even cesarean section.
Choice B reason:
The statement “Maternal pelvis is gynecoid” is incorrect as a contributing cause for difficult labor. A gynecoid pelvis is the most favorable pelvic shape for childbirth. It is round and wide, providing ample space for the baby to pass through the birth canal. Women with a gynecoid pelvis typically experience smoother and less complicated deliveries.
Choice C reason:
The statement “Fetal attitude is in general flexion” is also incorrect as a contributing cause for difficult labor. General flexion is the normal fetal attitude, where the baby’s chin is tucked to the chest, and the limbs are flexed. This position allows the smallest diameter of the baby’s head to present first, facilitating an easier passage through the birth canal.
Choice D reason:
The statement “Fetal lie is longitudinal” is incorrect as a contributing cause for difficult labor. A longitudinal lie means that the baby’s spine is aligned with the mother’s spine, which is the normal and most common orientation for delivery. This position is generally favorable for childbirth.
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