A triage nurse finds a school-age child lying in the road following a school bus crash with multiple casualties. The child has a respiratory rate of 8/min, is unresponsive to verbal commands, and groans to painful stimuli. The nurse should assign the client which of the following triage tags?

Red

Yellow

Green

Black

Answer and Explanation

The Correct Answer is A

Choice A Reason:

A red tag is used to label those who cannot survive without immediate treatment but who have a chance of survival. The child’s respiratory rate of 8/min, unresponsiveness to verbal commands, and groaning to painful stimuli indicate severe injuries that require urgent medical attention. Immediate intervention is necessary to address potential life-threatening conditions.

Choice B Reason:

A yellow tag is assigned to those who require observation and possible later re-triage. Their condition is stable for the moment, and they are not in immediate danger of death. Given the child’s critical condition, a yellow tag would not be appropriate as it suggests the child can wait for treatment, which is not the case here.

Choice C Reason:

A green tag is for the “walking wounded” who will need medical care at some point after more critical injuries have been treated. This tag is not suitable for the child in question, as their condition is far from minor and requires immediate attention.

Choice D Reason:

A black tag is used for the deceased or those whose injuries are so severe that they are not expected to survive despite receiving care. While the child’s condition is critical, they still have a chance of survival with immediate treatment, making a black tag inappropriate.

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Correct Answer is A

Explanation

Choice A Reason:

A distended, board-like abdomen is a critical finding that can indicate peritonitis, a severe complication of appendicitis. Peritonitis occurs when the appendix ruptures, leading to infection spreading throughout the abdominal cavity. This condition requires immediate medical intervention to prevent further complications and potential sepsis.

Choice B Reason:

A WBC count of 15,000/mm³ is elevated and suggests an infection, which is common in appendicitis. However, it is not as immediately critical as signs of peritonitis. Elevated WBC counts are expected in cases of appendicitis but do not necessarily indicate a life-threatening emergency.

Choice C Reason:

Rebound tenderness over McBurney’s point is a classic sign of appendicitis and indicates localized inflammation. While it is an important diagnostic sign, it does not require immediate reporting compared to signs of peritonitis.

Choice D Reason:

A temperature of 37.3°C (99.1°F) is only slightly elevated and does not indicate a severe infection or complication. Fever is a common symptom of appendicitis but is not as critical as a distended, board-like abdomen.

A. Take aspirin as needed to reduce your pain. B. Reduce your dietary fiber intake. C. Apply dry heat to your abdomen when needed. D. Check your weight once per week.

Correct Answer is C

Explanation

Choice A Reason:

Taking aspirin is generally not recommended for pain management in polycystic kidney disease (PKD) patients. Aspirin can cause gastrointestinal bleeding and may affect kidney function, which is already compromised in PKD patients. Instead, acetaminophen is often recommended for pain relief.

Choice B Reason:

Reducing dietary fiber intake is not typically advised for PKD patients. In fact, a balanced diet with adequate fiber is important for overall health and can help manage symptoms such as constipation, which can be a concern for PKD patients.

Choice C Reason:

Applying dry heat to the abdomen can help alleviate pain associated with PKD. Heat therapy can relax muscles and reduce discomfort caused by the enlarged kidneys and cysts. This non-pharmacological approach is safe and can be effective in managing pain.

Choice D Reason:

Checking weight once per week is not sufficient for PKD patients. Regular monitoring of weight is important to detect fluid retention and other complications. It is generally recommended to check weight more frequently, such as daily, to promptly identify any significant changes.

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A triage nurse finds a school-age child lying in the road following a school bus crash with multiple casualties. The child has a respiratory rate of 8/min, is unresponsive to verbal commands, and groans to painful stimuli. The nurse should assign the client which of the following triage tags?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who has suspected appendicitis. Which of the following findings is the nurse’s priority to report to the provider?

Correct Answer is A

Explanation

A nurse is teaching a client who has a new diagnosis of polycystic kidney disease. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

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A triage nurse finds a school-age child lying in the road following a school bus crash with multiple casualties. The child has a respiratory rate of 8/min, is unresponsive to verbal commands, and groans to painful stimuli. The nurse should assign the client which of the following triage tags?

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