The nurse is performing triage after a mass shooting in a shopping mall. To which client does the nurse assign a black tag?

21-year-old with confusion

23-year-old with an open femur fracture

26-year-old with uncontrollable anxiety

29-year-old with full-thickness extremity burns

Answer and Explanation

The Correct Answer is D

A. A 21-year-old with confusion is usually classified as red (immediate priority) in mass casualty triage. Confusion may indicate hypoxia, shock, traumatic brain injury, or internal bleeding, all of which require rapid intervention to prevent death. This patient is potentially salvageable with prompt care.

B. A 23-year-old with an open femur fracture is generally classified as yellow (delayed priority). Open fractures are serious but not immediately life-threatening if the patient is hemodynamically stable. This patient can safely wait for treatment after more critical cases have been addressed.

C. A 26-year-old with uncontrollable anxiety but no physiologic compromise is considered green (minor/walking wounded). These patients may require psychological support, reassurance, and minor interventions but do not need immediate medical resources.

D. A 29-year-old with full-thickness extremity burns is assigned a black tag (expectant) in a mass casualty situation. Black-tagged patients have injuries incompatible with survival or require resources unlikely to save them in the current situation. Full-thickness burns covering a large area can lead to severe fluid loss, risk of infection and sepsis, impaired thermoregulation, and airway compromise if inhalation injury is present. In a resource-limited, mass casualty setting, these patients are unlikely to survive despite maximal intervention, so care is focused on comfort measures while resources are prioritized for salvageable patients.

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Correct Answer is C

Explanation

A. Administering stress ulcer prophylaxis(such as a proton pump inhibitor or H2 blocker) is a component of VAP prevention bundles, as gastric acid suppression reduces the risk of aspiration-related pneumonia. This statement is correct and does not indicate misunderstanding.

B. Elevating the head of the bed 30–45°is a key VAP prevention measure, as it decreases risk of aspiration of gastric contents. This statement demonstrates proper understanding.

C. Continuous deep sedation is not recommendedfor VAP prevention. Over-sedation increases immobility, delays weaning, and increases the risk of VAP. The preferred practice is daily sedation interruption or light sedation, allowing assessment of readiness for weaning and reducing complications. This statement indicates the family needs additional teaching about sedation practices.

D. Low-dose anticoagulation (e.g., heparin) is used for venous thromboembolism (VTE) prophylaxisin mechanically ventilated patients and is part of standard critical care bundles. It does not directly prevent VAP but is appropriate care.

A. Administer prescribed antibiotics. B. Obtain blood cultures and other labs. C. Insert an indwelling urinary catheter. D. Initiate intravenous fluid resuscitation.

Correct Answer is D

Explanation

A. While antibiotics are essential to treat the infection, the client is showing signs of septic shock(hypotension, tachycardia, tachypnea, hypoxemia). Antibiotics alone will not immediately stabilize the patient’s circulatory compromise. Early fluid resuscitation takes priority to restore perfusion.

B. Blood cultures are necessary for guiding antibiotic therapy and identifying pathogens, but obtaining labs does not address the immediate hemodynamic instability. Delaying resuscitation while awaiting lab results can worsen organ perfusion.

C. Catheterization may be useful for monitoring urine output, which reflects perfusion, but it is not the first intervention. Immediate stabilization of blood pressure and circulation takes precedence.

D. The client’s low blood pressure (92/44), tachycardia (HR 134), tachypnea (RR 26), and hypoxemia (SpO2 90%)indicate septic shock with hypoperfusion. Rapid IV fluid administration (usually isotonic crystalloids) is the priority interventionto restore circulating volume, improve tissue perfusion, and prevent progression to multi-organ dysfunction.

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The nurse is performing triage after a mass shooting in a shopping mall. To which client does the nurse assign a black tag?

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Naxlex Comprehensive Predictor Exams

The nurse is teaching the spouse of a client on mechanical ventilation about measures to prevent ventilator associated pneumonia. Which of the following statements by the family would indicate to the nurse that the family would indicate to the nurse that the family needs additional instruction?

Correct Answer is C

Explanation

A 39-year-old client is admitted with a severely abscessed tooth. The nurse assess vital signs of BP 92/44, HR 134, RR 26, Spo2 90% on room air, temperature 38.9° C. What is the priority nursing intervention?

Correct Answer is D

Explanation

Which of the following conditions can place a client at risk for acute respiratory distress syndrome (ARDS)?

A client in acute respiratory failure is classified as having ventilatory failure. The nurse understands that which finding is a potential extrapulmonary cause of ventilatory failure?

The nurse is caring for a client with cardiogenic shock. Which information obtained by the nurse would best suggest the patient is developing multiple organ dysfunction syndrome (MODS)?

A client with COPD has all of the following ABG changes from earlier today. Which change alerts the nurse to take immediate action to prevent harm?

Which assessment finding in a client in the refractory phase of shock requires immediate nursing intervention?

The nurse is caring for a client with severe bleeding from a wound. Which of the following intravenous solutions would the client most likely receive initially?