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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Related Questions
Correct Answer is D
Explanation
Choice A reason:
Measuring a client’s intake and output (I&O) is a task that can be performed by assistive personnel (AP). This task involves recording the amount of fluids a client consumes and excretes, which does not require the specialized skills of an LPN. Therefore, it is more appropriate to assign this task to the AP.
Choice B reason:
Obtaining a client’s weight is another task that can be delegated to assistive personnel (AP). This task involves using a scale to measure the client’s weight and recording the result. It is a routine task that does not require the advanced training of an LPN.
Choice C reason:
Providing postmortem care for a client can be performed by assistive personnel (AP) under the supervision of an RN or LPN. This task involves preparing the body after death, which includes cleaning and positioning the body. While LPNs can perform this task, it is not exclusive to their scope of practice and can be delegated to AP.
Choice D reason:
Inserting a nasogastric tube for a client is a task that requires the specialized skills and training of an LPN. This procedure involves inserting a tube through the client’s nose into the stomach, which requires knowledge of anatomy, sterile technique, and the ability to assess for complications. Therefore, this task should be assigned to the LPN.
Correct Answer is D
Explanation
Choice A reason:
Washing the cord daily with mild soap and water is not recommended. The best practice is to keep the umbilical cord stump clean and dry. Cleaning it with water and mild soap can be done if it gets dirty, but it should not be a daily routine as it might delay the drying process.
Choice B reason:
Applying petroleum jelly to the cord stump is not advised. The goal is to keep the stump dry to promote natural drying and falling off. Petroleum jelly can keep the area moist, which is counterproductive to the drying process.
Choice C reason:
Covering the cord with the diaper is not recommended. Instead, the diaper should be folded down below the umbilical cord stump to keep it exposed to air and prevent irritation from urine or stool3. This helps the stump to dry out and fall off naturally.
Choice D reason:
Giving a sponge bath until the cord stump falls off is the correct instruction. Submerging the baby in water can delay the drying and falling off of the stump. Sponge baths help keep the area dry and clean, promoting faster healing.
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