While triaging the wounded from a disaster, you note that one of the wounded is not breathing, radial pulse is absent, capillary refill >2 seconds, and does not respond to your commands. What color tag is assigned?
Green
Yellow
Red
Black
The Correct Answer is D
During triage in a disaster situation, a color tagging system is often used to prioritize and categorize the injured based on the severity of their injuries and the urgency of medical attention required. The colors commonly used in triage are:
● Green tag: Minor injuries that are non-urgent and can typically wait for medical treatment.
● Yellow tag: Injuries that are significant but not immediately life-threatening, requiring medical attention within a few hours.
● Red tag: Critical injuries that are life-threatening but still salvageable with prompt medical intervention.
● Black tag: Injuries that are severe and unsurvivable or incompatible with life. This tag is assigned to individuals who are deceased or have injuries that are beyond the resources available for treatment.
In the given scenario, the absence of breathing, absent radial pulse, prolonged capillary refill, and unresponsiveness indicate a critical condition with no signs of life. Therefore, a black tag would be assigned to this individual.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
To calculate the milliliters per hour (mL/hr) for the IV infusion, you divide the total volume (in milliliters) by the total time (in hours).
In this case, the total volume is 1 liter, which is equal to 1000 milliliters, and the total time is 6 hours.
So, you divide 1000 mL by 6 hours:
1000 mL / 6 hours = 166.67 mL/hr
Rounding off, the nurse will program the IV infusion device to infuse at approximately 167 mL/hr.
Correct Answer is D
Explanation
The development of nausea and increased upper abdominal bowel sounds after 24 hours of NG decompression in a patient with gastric outlet obstruction raises concerns for possible complications or changes in the patient's condition. Assessing the patient's vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, can provide important information about their circulatory status and overall stability.
While checking the patency of the NG tube is important, it is not the best immediate action in this situation. The nurse should first assess the patient's vital signs to ensure their stability before proceeding with further interventions.
Placing the patient in a recumbent position (lying down) or encouraging deep breathing and conscious relaxation may not address the underlying issue and could potentially exacerbate the symptoms. It is essential to assess the patient's vital signs and circulatory status to determine the appropriate course of action.
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