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 A
Explanation
Choice A reason:
The arterial blood gas (ABG) values of pH 7.26, HCO₃ 14, and PaCO₂ 30 indicate metabolic acidosis with partial respiratory compensation. Acute kidney injury (AKI) often leads to metabolic acidosis due to the kidneys’ inability to excrete acid and reabsorb bicarbonate. The low pH indicates acidosis, the low bicarbonate (HCO₃) reflects metabolic acidosis, and the low PaCO₂ shows that the respiratory system is trying to compensate by blowing off CO₂.
Choice B reason:
The ABG values of pH 7.49, HCO₃ 30, and PaCO₂ 40 indicate metabolic alkalosis. This condition is characterized by an elevated pH and bicarbonate level. Metabolic alkalosis is not typically associated with acute kidney injury. Instead, it can result from excessive bicarbonate intake, loss of gastric acid (e.g., vomiting), or diuretic use.
Choice C reason:
The ABG values of pH 7.26, HCO₃ 24, and PaCO₂ 46 suggest respiratory acidosis. The low pH indicates acidosis, but the normal bicarbonate level and elevated PaCO₂ point to a respiratory cause rather than a metabolic one. Respiratory acidosis occurs when the lungs cannot remove enough CO₂, leading to its accumulation. This is not a typical presentation of AKI.
Choice D reason:
The ABG values of pH 7.49, HCO₃ 24, and PaCO₂ 30 indicate respiratory alkalosis. The high pH and low PaCO₂ suggest that the patient is hyperventilating, leading to excessive CO₂ loss. This condition is not commonly associated with acute kidney injury, which more frequently causes metabolic acidosis.
Correct Answer is C
Explanation
Choice A reason: Aplastic anemia results in an increased rate of RBC destruction
Aplastic anemia does not result from an increased rate of red blood cell (RBC) destruction. Instead, it is characterized by the bone marrow’s inability to produce sufficient new blood cells, including RBCs, white blood cells, and platelets. This condition leads to pancytopenia, a deficiency of all types of blood cells.
Choice B reason: Aplastic anemia is associated with a decreased intake of iron
Aplastic anemia is not typically associated with a decreased intake of iron. Iron deficiency anemia is a different condition where the body lacks enough iron to produce hemoglobin. Aplastic anemia, on the other hand, is due to the failure of the bone marrow to produce adequate blood cells.
Choice C reason: Aplastic anemia results from decreased bone marrow production of RBCs
This statement is correct. Aplastic anemia occurs when the bone marrow fails to produce enough new blood cells. This can be due to various factors, including autoimmune disorders, exposure to toxic chemicals, certain medications, and viral infections. The decreased production of RBCs, along with other blood cells, leads to the symptoms associated with aplastic anemia.
Choice D reason: Aplastic anemia results in an inability to absorb vitamin B12
Aplastic anemia is not related to the absorption of vitamin B12. Pernicious anemia is the condition associated with an inability to absorb vitamin B12 due to a lack of intrinsic factor. Aplastic anemia is specifically related to the bone marrow’s failure to produce sufficient blood cells.
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