The flight nurse arrived on scene of a bomb explosion and is assisting in the triage of clients. The client is found lying on the ground, confused but obeying commands. The client has a deformity to his lower leg with good peripheral pulses but is unable to ambulate. Using the START triage, what acuity level should be assigned to this client?

Yellow.

Black.

Red.

Green.

Answer and Explanation

The Correct Answer is A

Choice A reason: In the START triage system, the yellow category is designated for clients who are unable to walk, but their condition is stable and does not require immediate life-saving intervention. This client, though confused, is obeying commands, has a deformity to his lower leg with good peripheral pulses, and is unable to ambulate. These factors indicate that the client's injuries need attention but are not immediately life-threatening, making the yellow category appropriate.

Choice B reason: The black category is for clients who are deceased or have injuries so severe that they are not expected to survive even with immediate medical intervention. This client does not fall into this category as he is responsive and his condition is stable.

Choice C reason: The red category is assigned to clients who require immediate life-saving intervention. Although the client is unable to walk and has a deformity to his lower leg, he is stable, obeys commands, and has good peripheral pulses. Thus, he does not meet the criteria for the red category.

Choice D reason: The green category is used for clients who can walk and have minor injuries that do not require urgent medical attention. This client is unable to ambulate, indicating that his condition is more serious than those in the green category.

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Correct Answer is C

Explanation

Choice A reason: Restricting visiting of the victims until the bodies are prepared is a procedural step that can be managed without immediate involvement. While it's important, it does not directly address the family's immediate emotional needs.

Choice B reason: Providing privacy for law enforcement to interview the family is necessary for the investigation, but it should not take precedence over addressing the family's immediate emotional distress.

Choice C reason: Offering a calm location for the family to cope and discuss their needs addresses the immediate emotional and psychological support that the family requires in the wake of a traumatic event. It provides them with a safe space to begin processing their grief and start the healing process.

Choice D reason: Calling the hospital chaplain is a valuable step for providing spiritual and emotional support, but the first priority is to offer a calm and safe environment for the family. The chaplain can then be called to assist in this supportive space.

A. "Several staff members have commented that you are not doing your fair share of work." B. "If you are not doing your share of work, I will have to inform the nurse manager." C. "I need to talk to you about unit expectations regarding delegating and completing tasks." D. "You have been very inconsiderate of others by not completing your share of the work."

Correct Answer is C

Explanation

Choice A reason: While this statement addresses the concern, it might come across as accusatory and could put the staff nurse on the defensive. It is important to approach the situation with a focus on problem-solving rather than blame.

Choice B reason: This statement is more of a threat and may not foster a collaborative environment. It could lead to resistance rather than cooperation. The goal should be to discuss expectations and find a solution together.

Choice C reason: This statement is constructive and sets the stage for a productive conversation. It emphasizes the need to clarify unit expectations and provides an opportunity for the staff nurse to understand and meet these expectations. It focuses on the tasks and responsibilities rather than the individual's shortcomings.

Choice D reason: This statement is likely to be perceived as judgmental and may strain the working relationship. It is important to approach the situation with empathy and a focus on resolving the issue rather than criticizing the individual.

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Naxlex Comprehensive Predictor Exams

A family in the emergency department is overwhelmed at the loss of several family members due to a shooting incident in the community. Which intervention should the nurse complete first?

Correct Answer is C

Explanation

A charge nurse notes that a staff nurse delegates a large number of tasks to the assistive personnel (AP). The nurses on the next shift also report that the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict?

Correct Answer is C

Explanation

A nurse discovers that a client was administered an antihypertensive medication in error. What would be the priority action for the nurse to do first?

A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report?

When planning the delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which element regarding the role of assistive personnel should the nurse consider when delegating tasks?

The nurse educator is instructing newly hired nurses about client rights and the legal obligations of hospital staff. Which of the following would be an example to use when describing an assault in a clinical situation?

The nurse is educating a transgender female client about the expected outcomes of estrogen therapy. Which statement made by the client would indicate the need for further teaching?

An experienced charge nurse is providing mentoring to a new charge nurse. The new charge nurse is making the shift assignment for a licensed practical nurse (LPN). Which assignment requires intervention by the experienced nurse?

The nurse educator is reviewing the role of a nurse advocate with a group of newly hired nurses to the hospital. Which of the following statements indicate the newly hired nurses understand the roles of a nurse advocate? (Select All That Apply)

The charge nurse is planning the staff assignment for the day. Which factors should the nurse consider when planning the assignment? (Select all that apply)