Take full exam for free

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?

Red tag

Black tag

Green tag

Yellow tag

Answer and Explanation

The Correct Answer is A

Choice A: Red tag

A red tag is assigned to patients who require immediate medical attention and intervention to survive. These patients have life-threatening injuries but have a high chance of survival if treated promptly. In this scenario, the client has a respiratory rate of 38, a weak and rapid pulse, and uncontrolled bleeding. These symptoms indicate severe physiological distress and potential shock, necessitating immediate intervention to prevent death. According to NATO triage guidelines, such critical conditions warrant a red tag to prioritize urgent care1.

Choice B: Black tag

A black tag is used for patients who are deceased or have injuries so severe that survival is unlikely even with immediate medical intervention. This category is also known as “expectant” and is used to allocate resources to those with a higher chance of survival. The client in this scenario, despite having severe symptoms, is not described as being beyond the possibility of survival, thus a black tag would not be appropriate1.

Choice C: Green tag

A green tag is assigned to patients with minor injuries who can wait for medical treatment without immediate risk to life. These patients are often referred to as “walking wounded.” The client’s symptoms of a high respiratory rate, weak and rapid pulse, and uncontrolled bleeding are far too severe to be classified under this category. Assigning a green tag would delay critical care, potentially leading to fatal outcomes1.

Choice D: Yellow tag

A yellow tag is for patients who have serious injuries but whose treatment can be delayed without immediate risk to life. These patients need medical attention but are stable enough to wait for a short period. Given the client’s symptoms, particularly the uncontrolled bleeding and signs of shock, delaying treatment could result in rapid deterioration. Therefore, a yellow tag would not be suitable in this case1.

Free Nursing Test Bank

Take full exam free

View Related questions

A. Hypertension B. Tinnitus C. Hypotension D. Tachycardia

Correct Answer is A

Explanation

Choice A reason:

Hypertension is a common manifestation of increased intracranial pressure (ICP). As ICP rises, the body attempts to maintain cerebral perfusion by increasing blood pressure. This compensatory mechanism helps ensure that the brain continues to receive adequate blood flow despite the elevated pressure.

Choice B reason:

Tinnitus, or ringing in the ears, is not a typical manifestation of increased ICP. While it can be a symptom of various conditions, it is not specifically associated with elevated intracranial pressure.

Choice C reason:

Hypotension, or low blood pressure, is not a manifestation of increased ICP. In fact, the body typically responds to increased ICP with hypertension to maintain cerebral perfusion. Hypotension would be concerning for other reasons but is not indicative of elevated intracranial pressure.

Choice D reason:

Tachycardia, or an increased heart rate, is not a primary manifestation of increased ICP. While changes in heart rate can occur with severe neurological conditions, hypertension is a more direct indicator of elevated intracranial pressure.

A. Identification of resources to meet anticipated needs B. Participation in comprehensive annual drills C. Internal and external communications D. Performing duties outside the typical job description E. Development of decontamination plan

Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason:

Identification of resources to meet anticipated needs is a critical component of disaster planning. Nurses play a key role in identifying the resources required for effective disaster response, including medical supplies, personnel, and equipment. This ensures that the hospital is prepared to meet the needs of patients during a disaster.

Choice B reason:

Participation in comprehensive annual drills is essential for disaster preparedness. Nurses are involved in these drills to practice and refine their response skills, ensuring they are ready to act effectively in a real disaster. Drills help identify gaps in the disaster plan and provide opportunities for improvement.

Choice C reason:

Internal and external communications are vital during a disaster. Nurses are involved in establishing and maintaining communication channels within the hospital and with external agencies. Effective communication ensures coordination and timely response, which are crucial for managing a disaster situation.

Choice D reason:

Performing duties outside the typical job description may occur during a disaster, but it is not a primary component of the disaster plan. The focus is on ensuring that all staff are prepared to perform their roles effectively. While flexibility is important, the disaster plan should primarily outline specific roles and responsibilities.

Choice E reason:

Development of a decontamination plan is an important aspect of disaster preparedness, especially in scenarios involving hazardous materials. Nurses contribute to creating and implementing decontamination protocols to protect patients and staff from exposure to harmful substances.

Free Nursing Test Bank

Correct Answer is A

Explanation

Correct Answer is ["A","B","C","E"]

Explanation

Quick Links

Resources

Free Nursing Test Bank

A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure (ICP)?

Correct Answer is A

Explanation

A nurse is working with the hospital disaster plan with the emergency operations committee. The nurse is aware that nursing is involved in which components of the disaster plan? SELECT ALL THAT APPLY

Correct Answer is ["A","B","C","E"]

Explanation

An occupational health nurse in the clinic of an industrial plant is developing a guidebook for clinic workers. Which of the following actions should the nurse include as a secondary prevention strategy?

A nursing preceptor is reviewing life expectancy in the twentieth century with a new nurse. The nurse should recognize that which of the following was most responsible for the dramatic increase in life expectancy during the twentieth century?

A nurse educator is teaching a group of students about the role of nurses in health promotion. The educator recognizes that the nurse who works in health promotion and safety for an automotive plant is functioning in what role?

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 nurse advises a client with osteoporosis to have three servings of milk or dairy products daily. Which of the following levels of prevention is being used by the nurse?

A nurse is caring for a client who has Parkinson’s disease and is starting to display bradykinesia. Which of the following is an appropriate action by the nurse?

A nurse is assessing a client who reports a severe headache and stiff neck. The nurse’s assessment reveals positive Kernig’s and Brudzinski’s signs. Which of the following actions should the nurse perform first?

A nurse is working with a community at risk for flooding. The nurse is aware that identification of at-risk populations, education of the residents about evacuation routes, and emergency shelters is an example of what level of the National Response Framework?

Quick Links

Resources