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 A

Explanation

Choice A reason: The sudden onset of a headache and numbness on one side of the body are potential signs of a stroke or other serious medical conditions. The most appropriate response is to assist the visitor to the emergency department for immediate evaluation and treatment. Time is critical in such scenarios, and prompt medical attention can significantly impact the outcome.

Choice B reason: While taking the visitor's blood pressure might provide some information, it is not sufficient to assess the severity of the symptoms. This action alone could delay necessary urgent care.

Choice C reason: Encouraging the visitor to lie down and see if the symptoms improve is not appropriate because it does not address the potential seriousness of the symptoms. Delaying medical evaluation could worsen the visitor's condition.

Choice D reason: Advising the visitor to call their primary care provider is not appropriate in this urgent situation. Immediate evaluation in the emergency department is necessary to rule out serious conditions like a stroke.

A. A client with lymphoma receiving inpatient chemotherapy. B. A client with heart failure with crackles bilaterally on 4 liters of oxygen. C. A client who is post-appendectomy with a paralytic ileus. D. A client with a nondisplaced tibia fracture that has been immobilized.

Correct Answer is D

Explanation

Choice A reason: A client with lymphoma receiving inpatient chemotherapy is likely to require close monitoring and ongoing treatment due to the potential complications associated with their condition and treatment. Discharging this client could put them at significant risk.

Choice B reason: A client with heart failure with crackles bilaterally on 4 liters of oxygen needs continuous medical supervision and care to manage their heart condition and oxygen levels. Discharging this client could exacerbate their heart failure and lead to serious health complications.

Choice C reason: A client who is post-appendectomy with a paralytic ileus is at risk of complications such as bowel obstruction and infection. They need to be closely monitored in the hospital until their condition stabilizes and they begin to recover from surgery.

Choice D reason: A client with a nondisplaced tibia fracture that has been immobilized is generally stable and can be safely discharged with appropriate instructions for home care. This client does not require intensive monitoring and can continue their recovery at home.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is working on the medical-surgical unit when a visiting family member reports the sudden onset of a headache and numbness on the left side of their body. The visitor asks the nurse to check their blood pressure. What is the most appropriate response by the nurse?

Correct Answer is A

Explanation

The nurse supervisor is working in a hospital that is in the path of a hurricane. Which of the following clients would be appropriate for immediate discharge?

Correct Answer is D

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 reviewing the laboratory results for a client who is scheduled for knee arthroplasty later in the day. Which laboratory value is most important to report to the health care provider before the surgery?

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?

The nurse at an ambulatory care clinic is participating in an active shooter drill. The shooter is rapidly approaching the nurse's location and the nurse cannot get to an exit. What next best action is appropriate?

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?