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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Increased urinary output is not a typical manifestation of peritonitis. Peritonitis, especially in the context of peritoneal dialysis, does not usually affect urinary output directly. Instead, it primarily affects the peritoneal cavity and can lead to symptoms such as abdominal pain and tenderness.
Choice B reason: Hyperactive bowel sounds are not commonly associated with peritonitis. In fact, peritonitis can lead to decreased bowel sounds due to the inflammation and irritation of the peritoneum, which can cause paralytic ileus (a temporary cessation of bowel movements).
Choice C reason: Bradycardia (a slower than normal heart rate) is not a typical symptom of peritonitis. Peritonitis can cause systemic symptoms such as fever and tachycardia (an increased heart rate) due to the body’s inflammatory response to infection.
Choice D reason: Nausea and vomiting are common manifestations of peritonitis. The inflammation of the peritoneum can irritate the gastrointestinal tract, leading to these symptoms. Additionally, peritonitis can cause abdominal pain, tenderness, and distention, which are also associated with nausea and vomiting.
Correct Answer is C
Explanation
Choice A reason:
Oxygen saturation of 95% is within the normal range (typically 95-100%) and indicates adequate oxygenation. However, it does not specifically indicate that the lung has re-expanded. Oxygen saturation can be influenced by various factors, including supplemental oxygen and overall respiratory function.
Choice B reason:
Occasional bubbling in the water seal chamber can indicate air leakage from the pleural space, which suggests that the lung has not fully re-expanded. Continuous or intermittent bubbling usually signifies that air is still escaping from the lung into the pleural space.
Choice C reason:
No fluctuations in the water seal chamber, also known as “tidaling,” is a key indicator that the lung has re-expanded. When the lung is fully expanded, the pleural space is eliminated, and there is no longer a pressure difference to cause fluctuations in the water seal chamber. This finding suggests that the lung is now in contact with the chest wall and functioning normally.
Choice D reason:
No reports of pleuritic chest pain can indicate that the client is experiencing less discomfort, but it is not a definitive sign that the lung has re-expanded. Pain levels can vary based on individual pain tolerance and the effectiveness of pain management strategies.
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