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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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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. Administer a tap water enema to a client who is constipated. B. Assess a new admission client who just transferred to the unit. C. Evaluate a client reporting new onset chest pain. D. Administer Morphine 1 mg IV push to a client for pain.

Correct Answer is A

Explanation

Choice A reason: Administering a tap water enema is within the scope of practice for an LPN. This task is a routine procedure that does not require the clinical judgment of a registered nurse (RN). The LPN can safely perform this task under the supervision of the RN.

Choice B reason: Assessing a new admission client is a comprehensive process that involves obtaining a detailed medical history, performing a thorough physical assessment, and developing an initial plan of care. This task requires the clinical judgment and decision-making skills of an RN, making it inappropriate to delegate to an LPN.

Choice C reason: Evaluating a client with new onset chest pain is a critical task that requires immediate attention and advanced assessment skills. It involves determining the cause of the chest pain, assessing the severity, and initiating appropriate interventions. This task must be performed by an RN due to the potential for serious underlying conditions such as myocardial infarction.

Choice D reason: Administering Morphine IV push requires specific knowledge about the medication, potential side effects, and monitoring for adverse reactions. This task involves clinical judgment and decision-making, making it inappropriate to delegate to an LPN. The RN is responsible for administering medications that require close monitoring and assessment.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is working on the neurological unit. Which task would be most appropriate to delegate to the unlicensed assistive personnel assigned to the unit?

Correct Answer is B

Explanation

The nurse and licensed practical nurse (LPN) are caring for a group of clients on a medical-surgical unit. The following tasks have been ordered on their clients. Which task would be most appropriate to assign to the LPN?

Correct Answer is A

Explanation

The nurse is caring for an adult client who is scheduled for surgery. The client is competent and neurologically intact. Who would be responsible for signing the informed consent?

The nurse is counseling a new client who identifies as a transgender female and is expressing the desire to start estrogen therapy for their transition. What potential complication will the nurse include in the client teaching?

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?

A nurse is caring for a client with a stroke and is scheduled for transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse from the sending facility? (Select All that Apply)

The newly hired nurse educator for the emergency department is reviewing the hospital disaster plan and policies and finds that it has not been reviewed with the staff for 3 years. Which finding would be most important for the nurse educator to address related to the disaster plan?

A nurse has several tasks to delegate to assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first?

The nurse is eating lunch in the hospital cafeteria, which is crowded with visitors and other staff. A health care provider approaches the nurse and asks, "How is my client Ms. Jones in room 312 doing?" Which response by the nurse would be most appropriate?