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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Free Nursing Study Resources

Correct Answer is ["5.3"]

Explanation

Step 1: Convert the child’s weight from pounds to kilograms.

Weight in pounds = 28 lb
Conversion factor = 1 kg ÷ 2.2 lb
Weight in kilograms = 28 lb ÷ 2.2
Result: 12.727 kg (rounded to three decimal places)

Step 2: Calculate the dose of acetaminophen in mg.

Dose required = 10 mg × Weight in kg
Dose required = 10 mg × 12.727 kg
Result: 127.27 mg (rounded to two decimal places)

Step 3: Determine the volume of acetaminophen solution needed in mL.

Concentration of acetaminophen = 120 mg ÷ 5 mL
Volume required (mL) = Dose required (mg) ÷ Concentration (mg/mL)
Volume required (mL) = 127.27 mg ÷ (120 mg ÷ 5 mL)
Result: 127.27 mg ÷ 24 mg/mL
Result: 5.303 mL (rounded to three decimal places)

Step 4: Round the volume to the nearest tenth.

Rounded result: 5.3 mL

Final Answer: The nurse should administer 5.3 mL of acetaminophen.

A. Bright yellow B. Bright red C. Dark amber D. Pale pink

Correct Answer is D

Explanation

Choice A reason: Bright yellow

Bright yellow urine is typically a sign of normal hydration and is not expected after a transurethral prostatectomy. This color does not indicate the presence of blood or other substances that might be expected following surgery.

Choice B reason: Bright red

Bright red urine indicates significant bleeding, which is not typical after the initial postoperative period. While some blood in the urine is expected immediately after surgery, bright red urine should be reported to a healthcare provider as it may indicate a complication.

Choice C reason: Dark amber

Dark amber urine is usually a sign of dehydration or the presence of bilirubin. It is not typically associated with the expected postoperative changes following a transurethral prostatectomy. This color does not reflect the expected mild bleeding that can occur after the procedure.

Choice D reason: Pale pink

Pale pink urine is expected following a transurethral prostatectomy due to the presence of small amounts of blood in the urine. This is a normal finding as the surgical site heals. The pale pink color indicates mild bleeding, which is common and usually resolves as the healing process continues.

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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

A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb. The amount available is acetaminophen 120 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["5.3"]

Explanation

A nurse is caring for a client who has undergone a transurethral prostatectomy. Following catheter removal, the nurse should inform the client that he should expect which of the following variations in the color of his urine?

Correct Answer is D

Explanation

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