A nurse working at an assisted living facility is helping emergency medical services (EMS) triage clients after a fire in the building. The 83-year-old client suffered smoke inhalation. The client is coughing with a respiratory rate of 36 and reports shortness of breath. Using the START triage, what acuity level should be assigned to this client?

Black

Green

Red

Yellow

Answer and Explanation

The Correct Answer is C

Choice A reason: The black category in the START triage system is for clients who are deceased or have injuries so severe that they are not expected to survive even with immediate medical intervention. This client is not in that category since they are conscious and breathing.

Choice B reason: The green category is for clients who are ambulatory with minor injuries and do not require urgent medical attention. This client is experiencing significant respiratory distress, which categorizes them as more urgent.

Choice C reason: The red category is for clients who need immediate life-saving intervention. This client's respiratory rate of 36 and shortness of breath indicate a severe respiratory distress that requires urgent medical attention.

Choice D reason: The yellow category is for clients who are unable to walk but have stable conditions that do not require immediate life-saving intervention. This client's condition is more severe and needs prompt intervention.

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Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason: The radiology department plays a crucial role in mass casualty incidents by providing imaging services to diagnose and assess the extent of injuries. Involving radiology in the drill planning process ensures that they are prepared to handle a sudden influx of patients.

Choice B reason: Hospital security is essential for managing crowd control, maintaining order, and ensuring the safety of patients, staff, and visitors during a mass casualty incident. Their involvement in the drill planning process is necessary to coordinate security measures effectively.

Choice C reason: Hospital housekeeping is responsible for maintaining cleanliness and sanitation, which is especially important during a mass casualty incident to prevent the spread of infections and ensure a safe environment for patient care. Their participation in the drill planning helps prepare them for increased demands.

Choice D reason: The dietary department, while important for overall patient care, is not immediately critical in the context of a mass casualty drill. The focus of such drills is typically on urgent medical care, security, and logistical coordination.

Choice E reason: The registration department is vital for efficiently processing and documenting patient information during a mass casualty incident. Their involvement in the drill planning process ensures that they are prepared to handle a large number of patients quickly and accurately.

A. A client with lymphoma receiving inpatient chemotherapy. B. A client with heart failure with crackles bilaterally on 4 liters of oxygen. C. A client who is post-appendectomy with a paralytic ileus. D. A client with a nondisplaced tibia fracture that has been immobilized.

Correct Answer is D

Explanation

Choice A reason: A client with lymphoma receiving inpatient chemotherapy is likely to require close monitoring and ongoing treatment due to the potential complications associated with their condition and treatment. Discharging this client could put them at significant risk.

Choice B reason: A client with heart failure with crackles bilaterally on 4 liters of oxygen needs continuous medical supervision and care to manage their heart condition and oxygen levels. Discharging this client could exacerbate their heart failure and lead to serious health complications.

Choice C reason: A client who is post-appendectomy with a paralytic ileus is at risk of complications such as bowel obstruction and infection. They need to be closely monitored in the hospital until their condition stabilizes and they begin to recover from surgery.

Choice D reason: A client with a nondisplaced tibia fracture that has been immobilized is generally stable and can be safely discharged with appropriate instructions for home care. This client does not require intensive monitoring and can continue their recovery at home.

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Naxlex Comprehensive Predictor Exams

The emergency department nurse manager would like to develop a mass casualty drill to help with the training of the staff. What other hospital departments should be involved in the drill planning process? (Select All that Apply)

Correct Answer is ["A","B","C","E"]

Explanation

The nurse supervisor is working in a hospital that is in the path of a hurricane. Which of the following clients would be appropriate for immediate discharge?

Correct Answer is D

Explanation

The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor asks the nurse, "How is Mary doing? She is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response?

A nurse is caring for a client with a stroke and is scheduled for transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse from the sending facility? (Select All that Apply)

The nurse is assessing a newly admitted client who appears upset and agitated. What would be the best action for the nurse to best assist this client?

The nurse is caring for a group of clients. After making initial rounds, which client is the nurse's priority?

The emergency department nurse is triaging clients arriving from a mass casualty incident. During the triage, the nurse confirms that each client has a disaster tag. What information should be placed on the tag for each client? (Select all that apply)

The nurse is caring for an adult client who is scheduled for surgery. The client is competent and neurologically intact. Who would be responsible for signing the informed consent?

The nurse is counseling a new client who identifies as a transgender female and is expressing the desire to start estrogen therapy for their transition. What potential complication will the nurse include in the client teaching?