The triage nurse is tagging victims of a train derailment. One patient has a sucking chest wound, BP 90/50, respirations 32, and is alert and able to respond to questions. Utilizing the identified chart
, which colored tag should the nurse assign to the patient?
1. red, immediate threat to life
2. yellow, requiring medical attention but no threat of loss of life
3. green, ambulatory with minor injuries
4. black, not expected to survive
Patients who are critically injured and require immediate intervention should be tagged red (immediate threat to life). These patients need the most support and emergency care. This would include patients with a respiratory rate above 30.
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A parent says to a nurse, "How do you know when my child needs these screening tests the doctor just mentioned?" Which response should the nurse make to the parent?
1. "Screening tests are administered at the ages when a child is most likely to develop a condition." 2. "Screening tests are done in the newborn nursery, and from these results, additional screening tests are ordered throughout the first two years of life." 3. "Screening tests are most often done when the doctor suspects something is wrong with the child." 4. "Screening tests are done at each office visit."
Which situations are examples of the nurse directing rather than delegating? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply
1. A nurse manager asks a staff nurse to participate in a standing hospital committee. 2. A staff nurse asks the assistant to sit with the roommate of a client who has just died. 3. During a code blue situation, a nurse tells another nurse to start an IV. 4. A nurse tells an assistant to move a client into the hallway during severe weather. 5. A nurse reminds assistants of standard protocol for evacuation in case of fire.
Someone who participates in the process of making decisions regarding health care management with individuals from various professions is a(n)
1. Advocate. 2. Collaborator. 3. Counselor. 4. Leader. 5. Role model.
Which nursing observation of the patient in intensive care indicates the patient is sleeping comfortably during NREM sleep?
a. Eyes closed, lying quietly, respirations 12, heart rate 60 b. Eyes closed, tossing in bed, respirations 18, heart rate 80 c. Eyes closed, mumbling to self, respirations 16, heart rate 68 d. Eyes closed, lying supine in bed, respirations 22, heart rate 66