The nurse is assisting in the care of clients during a mass casualty event.

Exhibits

For each client, click to specify if the client should be assigned a red, yellow, or black tag. A tag color may be assigned to more than one client.

Client 4

Client 2

Client 1

Client 3

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"}}

Rationale

Client 1: Red tag. This client has a significant loss of blood and a low heart rate, indicating they are in critical condition and need immediate intervention to survive.
Client 2: Yellow tag. This client has second-degree burns and is in pain, but their condition is stable and not immediately life-threatening.
Client 3: Black tag. This client is unresponsive with multiple severe burn injuries and Cheyne-Stokes respirations, indicating a very poor prognosis and unlikely survival.
Client 4: Red tag. This client is experiencing severe chest pain and shortness of breath, which could indicate a life-threatening condition such as a heart attack and requires immediate attention.

Nursing Test Bank

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Correct Answer is D

Explanation

A. While paranoia in a client with dementia can be concerning, it is not immediately life-threatening and may require additional support or medication adjustments.
B. Itching after receiving a dose of cefaclor may indicate an allergic reaction, but further assessment would be needed to determine the severity.
C. A weight gain of 1 kg (2.2 lb) in a client with heart failure should be monitored, but it is not an immediate concern unless accompanied by other symptoms of fluid overload.
D. The progression of a pressure ulcer from stage II to stage III indicates a worsening condition that requires urgent intervention to prevent further complications and potential infection, making it the highest priority to report.

A. The surgeon should delay surgery until he can obtain informed consent from a parent. B. The client's pediatrician can obtain implied consent. C. The surgeon can proceed with the surgery by invoking implied consent. D. The surgeon can obtain informed consent from the client's adult cousin.

Correct Answer is C

Explanation

A. Delaying surgery in a life-threatening situation could endanger the client, so waiting for parental consent is not required under emergency circumstances.
B. The pediatrician does not have the authority to provide implied consent; this legal principle applies directly to the care team in emergency situations.
C. In emergency situations where a minor requires immediate, life-saving treatment and a parent or legal guardian is not available, implied consent allows the surgeon to proceed with necessary interventions to prevent harm.
D. An adult cousin does not have legal authority to provide consent for a minor’s treatment unless specifically designated as a legal guardian.

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The nurse is assisting in the care of clients during a mass casualty event. Exhibits For each client, click to specify if the client should be assigned a red, yellow, or black tag. A tag color may be assigned to more than one client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is caring for a group of clients. The nurse should recognize that which of the following information is the highest priority to report to the nursing supervisor?

Correct Answer is D

Explanation

A nurse is caring for a 16-year-old client who was in a motor-vehicle crash and needs surgical intervention immediately. The staff cannot reach either of the client's parents. The nurse should identify that which of the following is true about obtaining consent?

Correct Answer is C

Explanation

A nurse at a rehabilitation facility is planning to attend an interprofessional team meeting to discuss a client who is recovering from abdominal surgery. Which of the following actions should the nurse take to prepare for the meeting?

A nurse is preparing to perform a dressing change for a client who has a nondraining, stage III pressure ulcer that is infected with methicillin-resistant Staphylococcus aureus (MRSA). Which of the following precautions should the nurse take?

A nurse is assisting in the review of infection control precautions implemented by staff in a facility. Exhibits Select 2 client situations that require follow-up by the infection control nurse.

A nurse notices that a client's health information is visible on an unattended computer screen at the nurses' station. Which of the following actions should the nurse take first?

A nurse is contributing to a quality improvement plan to improve the shift reporting process on the unit. Which of the following actions is the first step the nurse should suggest to promote a change in the reporting process?

A nurse is assisting in a client education class for fire safety in the home. Which of the following statements by a client indicates an understanding of the teaching?

A nurse in a long-term care facility is caring for a client who received a superficial burn from a heating pad that malfunctioned. After completing an incident report, which of the following actions should the nurse take?

The nurse is assisting in the care of clients during a mass casualty event.

Exhibits

For each client, click to specify if the client should be assigned a red, yellow, or black tag. A tag color may be assigned to more than one client.