A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

Choice A: Check the tubing connections for leaks is not an action that the nurse should take. Leaks in the tubing connections can cause continuous or intermitent bubbling in the water seal chamber, not in the suction control chamber. The water seal chamber is the part of the closed chest drainage system that prevents air from entering the pleural space and allows air to escape from the chest tube. The nurse should check the tubing connections for leaks if there is bubbling in the water seal chamber and tighten them if necessary.

Choice B: Check the suction control outlet on the wall is not an action that the nurse should take. The suction control outlet on the wall is the source of negative pressure that helps drain fluid and air from the pleural space and maintain a patent chest tube. The suction control chamber is the part of the closed chest drainage system that regulates the amount of negative pressure applied to the chest tube. The nurse should check the suction control outlet on the wall if there is no bubbling in the suction control chamber and adjust it as prescribed.

Choice C: Continue to monitor the client's respiratory status is an action that the nurse should take. Slow, steady bubbling in the suction control chamber is an expected finding that indicates that the suction is working properly and that there are no leaks in the system. The nurse should continue to monitor the client's respiratory status and assess for signs of respiratory distress, such as dyspnea, tachypnea, cyanosis, or decreased oxygen saturation.

Choice D: Clamping the chest tube is not an action that the nurse should take. Clamping the chest tube can cause a tension pneumothorax, which is a life-threatening condition characterized by a buildup of air in the pleural space that compresses the lung and shifts the mediastinum. The nurse should only clamp the chest tube temporarily and briefly for specific purposes, such as changing or troubleshooting the drainage system, or as prescribed by the provider.

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.