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
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.
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Correct Answer is C
Explanation
Choice A reason:
Administering an antipyretic can help reduce fever, which is a common symptom of meningococcal meningitis. However, this action does not address the immediate need to assess the extent of neurological impairment. While fever management is important, it is not the first priority in this situation.
Choice B reason:
Completing a vascular assessment is important to evaluate the client’s circulatory status, especially if there are signs of septicemia. However, in the context of suspected meningococcal meningitis, the priority is to assess the neurological status to determine the extent of central nervous system involvement. This will guide further treatment and interventions.
Choice C reason:
Assessing the cranial nerves is crucial in a client with suspected meningococcal meningitis. This assessment helps determine the extent of neurological impairment and can provide critical information about the progression of the disease. Early identification of neurological deficits can guide immediate and appropriate interventions to prevent further complications.
Choice D reason:
Decreasing environmental stimuli can help reduce discomfort for the client, especially if they are experiencing photophobia or other sensory sensitivities. However, this action does not address the immediate need to assess the client’s neurological status. It is a supportive measure that can be implemented after more critical assessments are completed.
Correct Answer is B
Explanation
Choice A: A negative-pressure isolation room
A negative-pressure isolation room is typically used for patients with airborne infections, such as tuberculosis or measles, to prevent the spread of infectious agents through the air. Scabies, however, is primarily transmitted through direct skin-to-skin contact and occasionally through contact with contaminated clothing or bedding. Therefore, a negative-pressure isolation room is not necessary for a scabies patient1.
Choice B: A private room
A private room is the most appropriate choice for a client with scabies. This type of room helps prevent the spread of the infestation to other patients and allows for better control of the environment. Scabies is highly contagious and can spread through direct contact with the infested person or indirectly through contaminated items. Isolating the patient in a private room minimizes the risk of transmission and allows for proper infection control measures to be implemented2.
Choice C: A semi-private room with a client who has pediculosis capitis
Placing a scabies patient in a semi-private room with another patient, even one with a different parasitic infection like pediculosis capitis (head lice), is not advisable. Both conditions are highly contagious, and cohabitation increases the risk of cross-contamination and further spread of both infestations. Each condition requires specific treatment and isolation protocols to effectively manage and prevent outbreaks3.
Choice D: A positive-pressure isolation room
A positive-pressure isolation room is designed to protect immunocompromised patients from external contaminants by ensuring that air flows out of the room rather than in. This type of room is not suitable for a scabies patient, as it does not address the primary mode of transmission for scabies, which is direct contact. The focus for scabies management should be on preventing direct and indirect contact with others4.