A nurse in an emergency department is assessing a client who was biten on the left leg by a poisonous snake. The client has placed elastic bandages snugly above and below the bite marks and is in no apparent distress. Which of the following actions should the nurse take?

The correct answer is: a. Place a black tag on the client’s upper body and attempt to help the next client in need.

Choice A: Place a black tag on the client’s upper body and attempt to help the next client in need.

In mass casualty incidents, the START (Simple Triage and Rapid Treatment) triage system is often used. According to this system, if a patient is apneic (not breathing) and does not resume breathing after repositioning the airway, they are considered deceased or non-salvageable and should be tagged with a black tag. This allows the nurse to focus on other victims who have a higher chance of survival.

Choice B: Start CPR

While starting CPR might seem appropriate in a normal setting, during a mass casualty incident, resources and time are limited. The priority is to save as many lives as possible. Performing CPR on an apneic patient with a weak pulse would take significant time and resources that could be used to help other victims with a higher chance of survival.

Choice C: Place a red tag on the client’s upper body and obtain immediate help from other personnel.

A red tag is used for patients who need immediate care and have a high chance of survival if treated promptly. Since the client remains apneic even after repositioning the airway, they do not meet the criteria for a red tag.

Choice D: Reposition the client’s upper airway a second time before assessing his respirations.

Repositioning the airway a second time is not recommended in the START triage system. If the patient does not resume breathing after the initial repositioning, they are considered non-salvageable.

Choice A: Provide frequent oral and nares care is the correct action for the nurse to take. Oral and nares care can help prevent infection, dryness, and irritation of the mucous membranes, which can be damaged by the pressure and friction of the tube. The nurse should also monitor the tube position, secure it with tape, and keep scissors at the bedside in case of emergency deflation.

Choice B: Keep the client in a supine position is not the correct action for the nurse to take. The supine position can increase the risk of aspiration, regurgitation, and gastric distension, which can worsen the bleeding and compromise the airway. The nurse should elevate the head of the bed to at least 30 degrees and use a semi-Fowler's or high-Fowler's position.

Choice C: Ambulating the client four times per day is not the correct action for the nurse to take. Ambulation can increase abdominal pressure and dislodge the tube, which can cause bleeding and perforation. The nurse should keep the client on bed rest and use passive range-of-motion exercises to prevent complications such as thromboembolism and muscle atrophy.

Choice D: Encouraging the client to consume clear liquids is not the correct action for the nurse to take. Clear liquids can increase gastric volume and acidity, which can aggravate the bleeding and interfere with hemostasis. The nurse should maintain a nothing-by-mouth status and provide intravenous fluids and nutrition as prescribed.