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 C

Explanation

A. Wearing protective eyewear is not typically required for dressing changes unless there is a risk of splashing or spraying of fluids.
B. A mask is not necessary for dressing changes unless there is a risk of respiratory droplet transmission, which is not applicable in this situation.
C. Using dedicated equipment for the client is crucial to prevent the spread of MRSA and ensure infection control.
D. Turning on the HEPA filtration system is not a standard practice for dressing changes and does not specifically address the infection control needs of the client with MRSA.

A. Inform the charge nurse of the need to reassign the client's care. B. Obtain informed consent from the client for the blood transfusion. C. Delegate the client's care to an RN. D. Access the nursing information system for guidelines about blood transfusions.

Correct Answer is B

Explanation

A. Informing the charge nurse of the need to reassign the client’s care is unnecessary unless the nurse is unable to provide safe and competent care for the transfusion.
B. Obtaining informed consent is essential before a blood transfusion to ensure the client is aware of the procedure's purpose, benefits, and potential risks.
C. Delegating the client's care to another RN may be appropriate if the nurse lacks competence with transfusions, but obtaining consent is a priority.
D. Accessing the nursing information system for transfusion guidelines is helpful, but obtaining consent takes precedence before proceeding with the transfusion.

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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 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?

Correct Answer is C

Explanation

A nurse receives change-of-shift report and learns that one of their assigned clients is scheduled to receive a blood transfusion. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who states, "I am leaving this hospital because I'm frustrated with my therapy." Which of the following actions should the nurse take?

A nurse has just received change-of-shift report for a group of clients. Which of the following strategies should the nurse use to help manage client care requirements throughout the shift?

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 charge nurse is observing the actions of the facility staff on the unit. Which of the following actions should the charge nurse identify as a possible legal issue?

A nurse is caring for a client who reports his medication was not given during the night shift for the past 3 nights. The medication administration record indicates the medication was given. Which of the following actions by the nurse is appropriate?

A nurse is assisting with the plan of care for a client. Which of the following activities should the nurse include in the implementation phase of the nursing process?

A nurse working on an acute care unit is supervising a team of assistive personnel (AP). Which of the following actions by the nurse is an example of laissez-faire leadership?

A nurse is reviewing his client care assignments after receiving change-of-shift report. The nurse should notify the charge nurse that which of the following tasks should be reassigned to an RN?

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.