After a mass casualty event, which client will the nurse triage with a yellow tag? 1.25 Points
29-year old with third-degree burns over 80% of the body
36-year old with closed fractures of both legs
48-year old with wheezing and difficulty breathing
52-year old with multiple abrasions and contusions
The Correct Answer is B
A. This client would be triaged red or black depending on the setting. Extensive third-degree burns over 80% of the body are life-threatening, often requiring immediate advanced care (red) or may be considered unsalvageable in a mass casualty setting (black) if resources are limited.
B. Closed fractures are serious but not immediately life-threatening. In mass casualty triage, this client would receive a yellow tag (delayed), meaning treatment can be delayed while priority is given to more critical patients.
C. Respiratory distress indicates a high-acuity condition, requiring immediate intervention. This client would be tagged red (immediate priority).
D. Abrasions and contusions are minor injuries, usually triaged green (minimal), meaning care can be delayed significantly and the patient is considered walking wounded.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. An ankle fractureis painful and requires medical attention, but it is not immediately life-threatening. This client can be triaged after patients with more urgent cardiovascular or systemic emergencies.
B. Vomiting and flank pain from a history of kidney stonescan cause dehydration and severe discomfort, but it is not immediately life-threateningunless complications such as obstruction or infection occur.
C. Profound weakness and fever of 103° Findicate a possible infection that requires prompt evaluation, but the client is currently less acutely at risk for sudden deteriorationcompared with someone having possible acute coronary syndrome.
D. Sweating, jaw pain, and pain in the left armare classic signs of acute myocardial infarction (heart attack). This condition is life-threateningand requires immediate triage and intervention. Prompt recognition and rapid treatment can prevent cardiac tissue damage and reduce mortality.
Correct Answer is ["A","C","D","F"]
Explanation
A. Adherence to proper hand hygieneis correct because hand hygiene is one of the most effective measures to prevent healthcare-associated infections, including ventilator-associated pneumonia (VAP). Proper handwashing or use of alcohol-based sanitizer before and after patient contact reduces transmission of pathogens.
B. Administering a prescribed proton pump inhibitoris incorrect because proton pump inhibitors (PPIs) reduce stomach acidity, which can actually increase the risk of VAPby allowing colonization of the gastrointestinal tract with pathogenic bacteria that can be aspirated into the lungs.
C. Elevating the head of the bedis correct because keeping the head of the bed elevated at 30–45°reduces the risk of aspiration of gastric contents, a major contributor to VAP.
D. Providing oral care per protocolis correct because oral hygiene with antiseptic solutions (e.g., chlorhexidine) decreases colonization of pathogenic bacteria in the oropharynx, lowering the risk of ventilator-associated pneumonia.
E. Suctioning the client every houris incorrect because routine or frequent suctioning is not recommended and can increase trauma or introduce infection. Suctioning should be performed as neededbased on assessment of secretions.
F. Turning and positioning the client at least every 2 hoursis correct because frequent repositioning helps mobilize secretions, prevent pooling of fluids, and reduce the risk of atelectasis and infection, which can contribute to VAP.
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