The emergency department nurse is triaging clients arriving from a mass casualty incident. During the triage, the nurse confirms that each client has a disaster tag. What information should be placed on the tag for each client? (Select all that apply)

Client information when possible.

Triage priority.

Next of kin information.

Decontamination if applicable.

Medications and treatments administered.

Answer and Explanation

Correct Answer : A,B,C,D,E

Choice A reason: Including client information on the disaster tag is crucial for identification and tracking purposes. This information ensures that each client can be accurately identified, which is essential for providing appropriate care and for communication with family members and other healthcare providers.

Choice B reason: Triage priority is an essential piece of information that indicates the level of urgency for each client's care. This prioritization helps healthcare providers quickly identify which clients need immediate attention and which can wait, thereby optimizing the use of limited resources during a mass casualty incident.

Choice C reason: Next of kin information is important for contacting family members and loved ones in case of emergency. This information is essential for communicating the client's status, obtaining additional medical history, and providing support to the family during a stressful time.

Choice D reason: Decontamination information, if applicable, indicates whether the client has undergone decontamination procedures. This is critical for ensuring that contaminated clients do not pose a risk to others, including healthcare providers and other patients, and for maintaining a safe environment within the healthcare facility.

Choice E reason: Documenting medications and treatments administered is vital for continuity of care. This information allows healthcare providers to track what treatments have been given, avoid duplication of medications, and monitor the client's response to treatment. It also ensures that any subsequent healthcare providers have a complete record of the client's care.

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Correct Answer is B

Explanation

Choice A reason: Administering tube feedings to a quadriplegic client is a task that typically requires specialized training and knowledge to ensure it is performed safely and correctly. This task is often reserved for licensed nursing personnel due to the potential complications that can arise, such as aspiration or incorrect tube placement. Therefore, it is not appropriate to delegate this task to unlicensed assistive personnel (UAP).

Choice B reason: Assisting with bowel training by placing the client on the bedside commode is an appropriate task to delegate to unlicensed assistive personnel. This task involves providing physical assistance and support to the client, which falls within the scope of practice for UAP. It does not require specialized nursing knowledge or skills, making it suitable for delegation.

Choice C reason: Observing the client demonstrating a self-catheterization technique is a task that requires clinical judgment and assessment skills to ensure the client is performing the procedure correctly and safely. This responsibility is typically within the scope of practice for licensed nurses rather than UAP.

Choice D reason: Teaching Crede's maneuver to a client needing to void involves providing instruction and education on a specific technique to assist with bladder emptying. This teaching role requires specialized knowledge and skills, making it more appropriate for licensed nursing personnel. It is not suitable for delegation to UAP.

A. Documenting the client's fingerstick blood glucose during insulin infusion. B. Monitoring vital signs during a blood transfusion. C. Examining output from a client's surgically placed drain. D. Obtaining the central venous pressure measurements.

Correct Answer is A

Explanation

Choice A reason: Documenting the client's fingerstick blood glucose is a task that can be safely delegated to the UAP. This task involves recording a numeric value from a glucometer reading, which does not require clinical judgment or decision-making. UAPs are trained to perform and document such routine measurements accurately.

Choice B reason: Monitoring vital signs during a blood transfusion should not be delegated to a UAP. This task requires clinical judgment to identify and respond to potential adverse reactions, such as transfusion reactions, which is within the scope of practice for licensed nurses, not UAPs.

Choice C reason: Examining output from a client's surgically placed drain involves assessing the amount, color, and type of drainage, which requires clinical judgment to determine the significance of the findings. This task should be performed by a licensed nurse who can evaluate the client's condition and respond appropriately.

Choice D reason: Obtaining central venous pressure (CVP) measurements is a complex procedure that requires specialized knowledge and skills. It involves understanding hemodynamic monitoring and interpreting the measurements, which falls within the scope of practice for licensed nurses, not UAPs.

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The emergency department nurse is triaging clients arriving from a mass casualty incident. During the triage, the nurse confirms that each client has a disaster tag. What information should be placed on the tag for each client? (Select all that apply)

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Correct Answer is A

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