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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason:

Monitoring the client’s calf for edema is important in assessing for complications such as deep vein thrombosis (DVT) or compartment syndrome, but it is not the primary technique for assessing neurovascular status. Edema can indicate fluid accumulation and potential vascular issues, but it does not directly assess the nerve function or blood flow to the extremity.

Choice B reason:

Palpating the femoral pulse is crucial in assessing the neurovascular status of a client with a femur fracture. The femoral pulse provides information about the blood flow to the lower extremity. A strong, palpable pulse indicates good arterial blood flow, while a weak or absent pulse may suggest vascular compromise, which requires immediate attention. This assessment helps ensure that the blood supply to the limb is adequate, which is vital for healing and preventing complications.

Choice C reason:

Measuring the circumference of the thigh can help monitor for swelling and changes in muscle mass, but it is not a direct assessment of neurovascular status. While it can provide useful information about the extent of swelling or atrophy, it does not evaluate the nerve function or blood flow directly.

Choice D reason:

Instructing the client to wiggle his toes is a useful technique to assess motor function and nerve integrity. However, it is not sufficient on its own to assess the entire neurovascular status. It should be part of a comprehensive assessment that includes checking pulses, sensation, and capillary refill.

A. Raw celery B. Grapes C. Peanut butter D. Sliced bananas

Correct Answer is D

Explanation

Choice A reason: Raw celery is not recommended for toddlers as it can be a choking hazard due to its stringy texture and difficulty in chewing. Toddlers have smaller airways and less developed chewing skills, making raw celery a risky snack option.

Choice B reason: Grapes can also be a choking hazard for toddlers if not prepared properly. Whole grapes are the perfect size to block a toddler’s airway. If grapes are to be given, they should be cut into small, manageable pieces to reduce the risk of choking.

Choice C reason: Peanut butter is a nutritious option but should be given with caution. It can be sticky and difficult for toddlers to swallow, posing a choking risk. It is best to spread peanut butter thinly on bread or mix it with other foods to make it easier to consume.

Choice D reason: Sliced bananas are an excellent snack for toddlers. They are soft, easy to chew, and unlikely to cause choking. Bananas are also rich in essential nutrients like potassium and vitamins, making them a healthy choice.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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