Nokea
A nurse is performing disaster triage at a field hospital following a structural collapse. Advanced life support resources are limited. Which client should be assigned a black tag?
- A. A client with a penetrating head wound, unresponsive to pain, irregular respirations, and a fixed, dilated pupil
- B. A client with a chest wall bruise, shallow respirations, and tracheal deviation to the right
- C. A client with an open femur fracture, cool extremity, delayed capillary refill, and confusion
- D. A client who is found conscious, but unable to move the legs, with a distended abdomen and bruising across the lower torso
Correct Answer: A
Rationale: A black tag (A) is assigned to clients unlikely to survive, such as one with a penetrating head wound, unresponsive, irregular respirations, and fixed pupil, indicating severe brain injury. Chest trauma (B), femur fracture (C), and spinal/abdominal injury (D) have higher survival potential.
You may also like to solve these questions
The nurse is gathering evidence for a quality improvement committee focused on fall prevention. To provide the highest quality scholarly evidence, the nurse plans on gathering findings from
- A. expert opinions.
- B. randomized controlled trials (RCTs).
- C. C. quantitative studies.
- D. D. qualitative studies.
Correct Answer: B
Rationale: Randomized controlled trials (B) provide the highest level of evidence for fall prevention due to their rigorous methodology. Expert opinions (A), quantitative studies (C), and qualitative studies (D) are lower in the evidence hierarchy.
The nurse enters a client's room and finds the client lying on the floor and appearing unresponsive. The nurse should initially
- A. initiate a code blue.
- B. assess the client's respiratory effort.
- C. assess the carotid pulse.
- D. shout the client's name.
Correct Answer: B
Rationale: Assessing respiratory effort (B) is the initial step for an unresponsive client to determine if breathing is present, guiding further action. Shouting (D), checking pulse (C), or initiating a code (A) follow assessment.
The community health nurse has been notified of several incidents. Which situation requires immediate follow-up? A client with
- A. pulmonary tuberculosis (TB) is still testing positive despite 2 months of treatment.
- B. hepatitis A who works as a cook at a local healthcare facility.
- C. human immunodeficiency virus (HIV) with an undetectable viral load (VL) and reports having recent unprotected sexual intercourse.
- D. Lyme disease and is refusing further treatment with intravenous antibiotics because of nausea and vomiting.
Correct Answer: B
Rationale: Hepatitis A in a cook (B) poses an immediate public health risk due to potential foodborne transmission, requiring urgent follow-up. Persistent TB (A), HIV with undetectable load (C), and Lyme disease refusal (D) are less immediate threats.
A nurse is delegating tasks to the unlicensed assistive personnel (UAP). Which task is most appropriate for the UAP to perform?
- A. Assisting a client with dysphagia during oral feedings.
- B. Documenting a client’s response to a medication administered for pain relief.
- C. Collecting a clean-catch urine sample from a client.
- D. Removing a client’s indwelling urinary catheter per the provider’s order.
Correct Answer: C
Rationale: Collecting a clean-catch urine sample (C) is a non-invasive task within the UAP’s scope. Feeding with dysphagia (A), documenting medication response (B), and catheter removal (D) require clinical judgment or training beyond UAP scope.
The charge nurse plans client care assignments for an unlicensed assistive personnel (UAP) and a licensed practical/vocational nurse (LPN/VN) in the medical-surgical unit. Which activity should the charge nurse delegate to the LPN/VN to maximize staff resources?
- A. Perform wound care and dressing changes
- B. Collect routine vital signs (VS)
- C. Turn all bedbound clients every two hours
- D. Ambulate clients with ambulation orders
Correct Answer: A
Rationale: Wound care and dressing changes (A) utilize the LPN/VN’s clinical skills, maximizing resources. Vital signs (B), turning (C), and ambulation (D) are within UAP scope, allowing the LPN/VN to focus on higher-skill tasks.