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 B

Explanation

Choice A Reason

A client who has a chest tube and reports a pain level of 6 on a scale of 0 to 10. While pain management is important, this client is not in immediate life-threatening danger. Pain can be addressed after ensuring there are no urgent allergic reactions or other critical conditions.

Choice B Reason

A client who received parenteral cephalosporin and reports urticaria and edema. This is the correct choice. Urticaria (hives) and edema (swelling) can indicate an allergic reaction, which can progress to anaphylaxis, a life-threatening condition. Immediate assessment and intervention are required to prevent severe complications.

Choice C Reason

A client who is being admitted with bilateral stage 3 pressure injuries on both heels. While stage 3 pressure injuries are serious and require prompt attention, they do not pose an immediate life-threatening risk compared to a potential anaphylactic reaction.

Choice D Reason

A client who has a systemic infection and an oral temperature of 39.1°C (102.4°F). Although a systemic infection with a high fever is concerning and needs timely intervention, it is not as immediately life-threatening as a potential anaphylactic reaction.

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 receiving report on a group of clients. Which of the following clients should the nurse assess first?

Correct Answer is B

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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