A school nurse is helping emergency medical services (EMS) triage students after a bus accident occurred in the school parking lot. A 10-year-old client is awake, alert, and ambulatory but reports a headache and neck pain. Using START triage, what acuity level would be assigned to this client?

Red

Green

Black

Yellow

Answer and Explanation

The Correct Answer is D

Choice A reason: The red category in START triage is reserved for clients who need immediate intervention to survive. This includes those with life-threatening injuries such as severe bleeding or airway obstruction. In this scenario, the 10-year-old client is awake, alert, and ambulatory, indicating that their condition is not immediately life-threatening. Therefore, the red category is not applicable.

Choice B reason: The green category is used for clients who are able to walk and have minor injuries. While the 10-year-old client is ambulatory, the presence of a headache and neck pain suggests that their injuries might be more severe than minor. The green category would not be appropriate because their symptoms indicate a need for further evaluation and monitoring.

Choice C reason: The black category is assigned to clients who are deceased or have injuries so severe that survival is unlikely even with immediate medical intervention. The 10-year-old client is awake, alert, and able to walk, which clearly does not align with the criteria for the black category. Therefore, this category is not suitable for the client's condition.

Choice D reason: The yellow category in START triage is for clients who require medical attention but their injuries are not immediately life-threatening. Given that the 10-year-old client is reporting a headache and neck pain, there is a potential risk of underlying injury that warrants attention but does not require immediate intervention. Thus, the yellow category is the most appropriate acuity level for this client.

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Correct Answer is C

Explanation

Choice A reason: Conducting a study about the time and money costs of implementing the change is valuable for understanding the resource implications of the measures. However, it does not directly evaluate the effectiveness of the changes in reducing medication errors.

Choice B reason: Providing the staff with a questionnaire to quantify staff satisfaction with the changes can offer insights into how well the measures are being received by the staff and may indicate potential areas for improvement in implementation. Nonetheless, it does not measure the direct impact on medication error rates.

Choice C reason: Comparing the number of medication errors before and after the action was implemented is the most direct and effective method to evaluate the success of the changes. This approach allows the committee to measure the actual impact of the interventions on reducing medication errors, providing clear evidence of their effectiveness.

Choice D reason: Establishing a benchmark to identify a standard of performance is essential for setting goals and expectations. However, it is not a method for evaluating the success of changes that have already been implemented. It is more relevant for future goal-setting and performance measurement.

A. Heart rate of 104 bpm B. Tympanic temperature of 102.6°F (39.2°C) C. Blood pressure of 158/90 mmHg D. Respiratory rate of 24 breaths/min

Correct Answer is B

Explanation

Choice A reason: A heart rate of 104 bpm can be expected in a client with pneumonia and after suctioning. Tachycardia (elevated heart rate) can occur as a response to infection, stress, or the suctioning procedure itself. While it should be monitored, it is not the most critical finding.

Choice B reason: A tympanic temperature of 102.6°F (39.2°C) is unexpected and indicates a significant fever, which may suggest a worsening infection or sepsis. This finding requires immediate attention as it could indicate that the current treatment for pneumonia is not effective, and the client's condition may be deteriorating.

Choice C reason: A blood pressure of 158/90 mmHg, though elevated, may be less critical in the context of this client's condition. Hypertension can occur due to various factors, including stress and illness, and should be monitored but is not the most urgent priority compared to a high fever.

Choice D reason: A respiratory rate of 24 breaths/min is slightly elevated but can be expected in a client with pneumonia and after suctioning. This rate indicates mild tachypnea, which should be monitored but is not as immediately concerning as a high fever.

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A school nurse is helping emergency medical services (EMS) triage students after a bus accident occurred in the school parking lot. A 10-year-old client is awake, alert, and ambulatory but reports a headache and neck pain. Using START triage, what acuity level would be assigned to this client?

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Naxlex Comprehensive Predictor Exams

As a member of the quality improvement committee, a nurse is evaluating the results of recently implemented measures designed to reduce medication errors. Which of the following methods should the nurse use to evaluate the success of the changes?

Correct Answer is C

Explanation

The nurse is assessing a mechanically ventilated client with pneumonia after providing deep oral suctioning to the client. Which assessment finding would be unexpected and be a priority for the nurse to address?

Correct Answer is B

Explanation

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A school nurse is helping emergency medical services (EMS) triage students after a bus accident occurred in the school parking lot. A 10-year-old client is awake, alert, and ambulatory but reports a headache and neck pain. Using START triage, what acuity level would be assigned to this client?

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