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: I would be happy to do whatever I can to help you. While this response shows empathy and a willingness to help, it does not address the fact that shopping for the client is outside the nurse’s job description. It is important for the nurse to adhere to professional boundaries and find appropriate solutions within those limits.
Choice B reason: What I think you should do is wait for the days when you feel better and do your grocery shopping then. This response is not practical or supportive. It does not provide a solution for the client’s immediate needs and may come across as dismissive of her current difficulties.
Choice C reason: I won’t be able to shop for you today because I have to get home to my family. This response is honest but lacks empathy and does not offer any alternative solutions. It may leave the client feeling unsupported and frustrated.
Choice D reason: Let’s look at some other resources to solve this problem. This response is the most appropriate as it acknowledges the client’s needs and seeks to find a solution within the nurse’s professional boundaries. The nurse can help the client explore options such as grocery delivery services, community resources, or assistance from family and friends.
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.
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