The nurse is working in the emergency department and is receiving multiple clients from a mass casualty incident. The client arrives by ambulance and is awake, alert, and oriented, complaining of severe abdominal pain with nausea and vomiting. The client's respiratory rate is 20 and has a good radial pulse with normal capillary refill. How would you triage this client using the START triage?

Red

Yellow

Black

Green

Answer and Explanation

The Correct Answer is B

Choice A reason: The red category in the START triage system is assigned to clients who require immediate life-saving intervention. Although this client is in pain and has severe symptoms, their respiratory rate, pulse, and capillary refill are normal, indicating that they do not need immediate life-saving intervention.

Choice B reason: The yellow category is designated for clients whose condition is stable but requires observation. This client is awake, alert, and oriented, with a normal respiratory rate, good radial pulse, and normal capillary refill. While they have severe abdominal pain and nausea, their condition does not appear to be life-threatening, making yellow the appropriate triage level.

Choice C reason: The black category is used for clients who are deceased or have injuries so severe that they are not expected to survive even with immediate medical intervention. This client is stable and responsive, so they do not fall into this category.

Choice D reason: The green category is for clients with minor injuries who can walk and do not require urgent medical attention. Since this client has severe symptoms and needs medical attention, the green category is not appropriate.

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Correct Answer is C

Explanation

Choice A reason: Conducting a study about the time and money costs of implementing the change is valuable for understanding the resource implications of the measures. However, it does not directly evaluate the effectiveness of the changes in reducing medication errors.

Choice B reason: Providing the staff with a questionnaire to quantify staff satisfaction with the changes can offer insights into how well the measures are being received by the staff and may indicate potential areas for improvement in implementation. Nonetheless, it does not measure the direct impact on medication error rates.

Choice C reason: Comparing the number of medication errors before and after the action was implemented is the most direct and effective method to evaluate the success of the changes. This approach allows the committee to measure the actual impact of the interventions on reducing medication errors, providing clear evidence of their effectiveness.

Choice D reason: Establishing a benchmark to identify a standard of performance is essential for setting goals and expectations. However, it is not a method for evaluating the success of changes that have already been implemented. It is more relevant for future goal-setting and performance measurement.

A. A nurse giving report to the oncoming shift at the client's bedside B. A nurse shredding a client's printed laboratory results C. A nurse posting positive information about a client on social media D. A nurse logging off the computer before leaving the workstation

Correct Answer is C

Explanation

Choice A reason: While giving a report to the oncoming shift at the client's bedside might potentially expose confidential information, it is generally an accepted practice in many healthcare settings as long as privacy is maintained and the patient consents.

Choice B reason: Shredding a client's printed laboratory results is actually a good practice to ensure that confidential information is disposed of securely, preventing unauthorized access.

Choice C reason: Posting any information about a client on social media, even if it is positive, is a direct breach of client confidentiality. This action exposes the client's personal health information to a wide audience, violating privacy regulations such as HIPAA.

Choice D reason: Logging off the computer before leaving the workstation is a good practice to protect client information from unauthorized access and does not represent a breach of confidentiality.

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Naxlex Comprehensive Predictor Exams

As a member of the quality improvement committee, a nurse is evaluating the results of recently implemented measures designed to reduce medication errors. Which of the following methods should the nurse use to evaluate the success of the changes?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

The ICU nurse is assigned to provide nursing care to a client receiving mechanical ventilation. Which action should you delegate to the experienced unlicensed assistive personnel (UAP)?

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?

A charge nurse notes that a staff nurse delegates a large number of tasks to the assistive personnel (AP). The nurses on the next shift also report that the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict?

The nurse is on her break in the hospital cafeteria when she overhears two nurses talking about a client's condition. The nurse understands this could lead to which of the following complaints?

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?