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During a mass casualty incident, a nurse must triage multiple victims using the SALT triage system. Which of the following actions demonstrate appropriate application of triage principles to optimize resource allocation and patient outcomes? (Select all that apply)

Assign a yellow tag to clients unable to walk but with stable vitals and no respiratory distress, indicating delayed care.

Allocate immediate resources to clients with severe injuries and very low likelihood of survival to attempt life-saving measures.

Tag as green clients who are alert, oriented, ambulatory, and have minor injuries such as abrasions or sprains.

Assign a red tag to a client who is breathing rapidly, has a weak pulse, and responds only to painful stimuli.

Perform detailed diagnostic assessments and treatments at the triage site for all clients before tagging.

Assign a red tag to an ambulatory client complaining of mild pain but with stable vital signs and no respiratory distress.

Provide comfort measures only to a client who is unresponsive and has no respirations after repositioning, assigning a black tag

Treat all clients in the order they arrive regardless of injury severity or survival potential.

Answer and Explanation

Correct Answer : A,C,D,G

Rationale:

A. Assign a yellow tag to clients unable to walk but with stable vitals and no respiratory distress, indicating delayed care is correct. Yellow tags indicate “delayed” or non-urgent care, appropriate for patients who need attention but can safely wait while more critical patients are treated first.

B. Allocate immediate resources to clients with severe injuries and very low likelihood of survival to attempt life-saving measures is incorrect. SALT triage prioritizes resources to maximize survivable outcomes, meaning patients unlikely to survive even with intervention are assigned a black tag (expectant) rather than receiving immediate resources.

C. Tag as green clients who are alert, oriented, ambulatory, and have minor injuries such as abrasions or sprains is correct. Green tags indicate “minor” or “walking wounded” patients who require minimal intervention, allowing resources to focus on higher-acuity patients.

D. Assign a red tag to a client who is breathing rapidly, has a weak pulse, and responds only to painful stimuli is correct. Red tags indicate “immediate” priority for life-threatening injuries where intervention can save the patient.

E. Perform detailed diagnostic assessments and treatments at the triage site for all clients before tagging is incorrect. SALT triage emphasizes rapid assessment to categorize patients, not detailed diagnostics, which would delay care for critically injured patients.

F. Assign a red tag to an ambulatory client complaining of mild pain but with stable vital signs and no respiratory distress is incorrect. Red tags are for life-threatening injuries, not minor complaints with stable vitals. This client should receive a green tag.

G. Provide comfort measures only to a client who is unresponsive and has no respirations after repositioning, assigning a black tag is correct. Black tags indicate expectant or deceased patients, and care focuses on comfort rather than attempting futile interventions.

H. Treat all clients in the order they arrive regardless of injury severity or survival potential is incorrect. SALT triage prioritizes acuity and survivability, not arrival time. Treating patients in order of arrival could delay care for critically injured patients.

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Correct Answer is C

Explanation

Rationale:
A. Patient with suicidal ideation with a sitter at the bedside with her back towards the patient is incorrect as the highest priority because, although patient safety is crucial, a sitter is present, and immediate life-threatening physiological compromise is not occurring. The situation should be corrected to ensure proper observation, but it is not more urgent than unstable vital signs.

B. Post-op patient with leg swelling and thready pedal pulses is incorrect as the highest priority because this indicates possible peripheral vascular compromise or early signs of deep vein thrombosis. While serious and requiring prompt assessment, it is not immediately life-threatening compared to rapidly falling blood pressure.

C. Patients with rapidly decreasing blood pressure is correct because hypotension can indicate shock, internal bleeding, or other life-threatening complications. Rapidly decreasing blood pressure threatens perfusion to vital organs and requires immediate intervention to prevent organ failure or death. According to ABC (Airway, Breathing, Circulation) and Maslow’s hierarchy of needs, circulation issues take the highest priority.

D. Patient requesting a second dose of pain medication is incorrect as the highest priority because pain management is important for comfort and quality of care, but it is not immediately life-threatening. Interventions for unstable vital signs take precedence over pain relief.

A. Ignore the behavior to avoid confrontation and maintain team harmony. B. Report the incident immediately to hospital administration without attempting direct communication. C. Respond with an equally harsh comment to assert authority and discourage future criticism. D. Request to discuss the issue privately using "I" statements to express feelings and seek clarification.

Correct Answer is D

Explanation

Rationale:
A. Ignore the behavior to avoid confrontation and maintain team harmony is incorrect because ignoring incivility allows the behavior to continue and can increase stress, anxiety, and job dissatisfaction. Avoidance does not resolve the conflict or promote a professional work environment.

B. Report the incident immediately to hospital administration without attempting direct communication is incorrect because while reporting may eventually be necessary, evidence-based strategies for addressing incivility recommend first attempting a direct, professional conversation to clarify the situation and address the behavior. Immediate escalation without communication may escalate tension unnecessarily.

C. Respond with an equally harsh comment to assert authority and discourage future criticism is incorrect because retaliation or responding in kind escalates conflict, models unprofessional behavior, and does not resolve the underlying issue.

D. Request to discuss the issue privately using "I" statements to express feelings and seek clarification is correct because evidence-based approaches to managing incivility emphasize professional, assertive communication. Using “I” statements allows the newly licensed nurse to express feelings without blaming the other person, encourages dialogue, and helps clarify expectations. This approach promotes conflict resolution, maintains professionalism, and models appropriate communication skills.

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During a mass casualty incident, a nurse must triage multiple victims using the SALT triage system. Which of the following actions demonstrate appropriate application of triage principles to optimize resource allocation and patient outcomes? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

Which situation takes the highest priority?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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