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A nurse is caring for a client brought to the Emergency Department as one of the first victims of a train accident. The nurse assesses the client, noting a respiratory rate of 38, a weak, rapid pulse, and uncontrolled bleeding. Using NATO guidelines, the nurse assigns which priority tag?
- A. Red tag
- B. Black tag
- C. Green tag
- D. Yellow tag
Correct Answer: A
Rationale: The correct answer is A: Red tag. The nurse assigns a red tag based on the assessment findings of a high respiratory rate, weak rapid pulse, and uncontrolled bleeding, indicating a critically injured patient requiring immediate intervention. Red tag signifies priority 1 according to NATO guidelines, indicating the need for immediate life-saving interventions. Other choices are incorrect because Black tag (B) is used for deceased or non-salvageable patients, Green tag (C) for minor injuries, and Yellow tag (D) for delayed or non-urgent care. In this scenario, the patient's critical condition necessitates the assignment of a red tag for prompt and urgent care.
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A nurse is determining if a homebound client is eligible for Meals-on-Wheels. Which of the following is the most important factor for the nurse to consider?
- A. The client's level of family support
- B. The client's financial resources
- C. The client's access to transportation
- D. The client's ability to prepare meals
Correct Answer: D
Rationale: The correct answer is D: The client's ability to prepare meals. This is crucial as Meals-on-Wheels provides food delivery for those unable to cook. By assessing the client's meal preparation ability, the nurse can determine if the service is necessary. Choice A may be helpful, but not as critical as the client's own ability. Choice B is important but not the most crucial for Meals-on-Wheels eligibility. Choice C is relevant, but if the client cannot prepare meals, transportation to get food is secondary.
A nurse is conducting triage of clients transported from a mass casualty incident (MCI). A client arrives saturated with an unknown substance and medical transport reports feeling dizzy. The nurse should prioritize which actions? SELECT ALL THAT APPLY
- A. Assign the client to a private room
- B. Remove client and transport crew from the Emergency department
- C. Contact decontamination team
- D. Call the scene to identify the chemical
- E. Immediately remove the saturated clothing from the client
Correct Answer: B,C,E
Rationale: Correct Answer: B, C, E
Rationale:
1. Option B - Removing the client and transport crew from the Emergency department is crucial to prevent potential contamination of others and ensure safety.
2. Option C - Contacting the decontamination team is essential to properly manage and decontaminate the client and the area.
3. Option E - Removing the saturated clothing from the client immediately helps eliminate further exposure and contamination risks.
Incorrect Answers:
A: Assign the client to a private room - This is not the priority as immediate decontamination and safety measures are needed.
D: Call the scene to identify the chemical - Identifying the substance is important but not the priority when the client's safety is at risk.
The nurse is creating an education plan for a client who has a recent diagnosis of Multiple Sclerosis (MS). Which of the following interventions should the nurse include in the client's plan?
- A. Recommend the client engage in high-impact, vigorous exercises to improve muscle strength
- B. Teach the client stress management techniques such as deep breathing and meditation
- C. Advise the client to avoid social interactions to minimize stress
- D. Encourage the client to void every hour
Correct Answer: B
Rationale: The correct answer is B: Teach the client stress management techniques such as deep breathing and meditation. This intervention is appropriate for a client with MS as stress can exacerbate symptoms. Deep breathing and meditation are proven techniques to reduce stress levels, promote relaxation, and improve overall well-being. By incorporating stress management techniques into the education plan, the nurse can help the client cope better with the emotional and physical challenges of living with MS.
Choice A is incorrect because high-impact, vigorous exercises can actually worsen symptoms and fatigue in clients with MS. Choice C is incorrect as social interactions can provide emotional support and should not be avoided. Choice D is incorrect as there is no specific indication for encouraging the client to void every hour in the context of MS.
A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?
- A. A negative-pressure isolation room
- B. A private room
- C. A semi-private room with a client who has pediculosis capitis
- D. A positive-pressure isolation room
Correct Answer: B
Rationale: The correct answer is B: A private room. This is because scabies is transmitted through close skin-to-skin contact, so placing the client in a private room will help prevent the spread of the infestation to others. A negative-pressure isolation room (choice A) is used for airborne infections, not for scabies. Placing the client in a semi-private room with a client who has pediculosis capitis (lice) (choice C) increases the risk of cross-infection. Positive-pressure isolation rooms (choice D) are used to protect immunocompromised clients from airborne pathogens.
A nurse is delegating tasks to the assistive personnel (AP). The nurse should direct the AP to complete which of the following tasks first?
- A. Assisting a client with a bed bath who has a history of falls
- B. Providing a snack to a diabetic client who is feeling lightheaded
- C. Feeding a client who has bilateral casts due to upper arm fractures
- D. Ambulating a postoperative client for the first time
Correct Answer: B
Rationale: The correct answer is B because providing a snack to a diabetic client who is feeling lightheaded addresses an immediate physiological need. Hypoglycemia can lead to serious complications and needs to be addressed promptly to prevent harm. Choices A, C, and D involve important tasks but do not address an urgent physiological need like hypoglycemia. Assisting a client with a bed bath, feeding a client with bilateral casts, or ambulating a postoperative client can be prioritized based on the client's condition and safety but do not take precedence over addressing a potential medical emergency like hypoglycemia.