A nurse is assisting with triage for group of clients following a mass casualty incident. Which of the following actions should the nurse take?

Check blood pressure for a client who is short of breath.

Identify arterial bleeding by the presence of dark red blood.

Open the airway of a client who has a cervical injury by using the jaw-thrust technique.

Request the assistance of another staff member to log roll a client.

Answer and Explanation

The Correct Answer is C

A) Check blood pressure for a client who is short of breath:
In a mass casualty incident, triage prioritizes addressing life-threatening conditions first. While shortness of breath may indicate a serious problem, assessing blood pressure would not be the most immediate action. The nurse should focus on airway, breathing, and circulation (the ABCs) before checking vital signs like blood pressure, as these could indicate the need for more urgent interventions.

B) Identify arterial bleeding by the presence of dark red blood:
Arterial bleeding is typically characterized by bright red blood that spurts or pulses with the heartbeat. Dark red blood is more indicative of venous bleeding. Recognizing arterial bleeding involves identifying the bright red, spurting blood, not dark red blood. It is essential to address major bleeding immediately by applying pressure or using a tourniquet as needed.

C) Open the airway of a client who has a cervical injury by using the jaw-thrust technique:
In clients with potential cervical spine injuries, the jaw-thrust technique is the recommended method to open the airway, as it does not involve tilting the head and neck, which could exacerbate a cervical injury. Ensuring the airway is patent is a priority in triage, and the jaw-thrust maneuver minimizes the risk of further injury to the spine.

D) Request the assistance of another staff member to log roll a client:
While log rolling is important for proper spinal alignment in clients with suspected spinal injuries, it is not the most urgent action during triage. In the context of a mass casualty incident, other immediate interventions, such as securing the airway and controlling bleeding, should take precedence before moving the patient unless the client’s condition requires repositioning to facilitate life-saving care.

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Correct Answer is A

Explanation

A) Position the client’s head toward Mecca: In Islam, it is customary to position the deceased's body with the head facing toward Mecca, the holy city of Islam. This is an important religious practice and should be followed during postmortem care to respect the deceased's cultural and religious beliefs.

B) Allow a family member of the client to stay with the client’s body until burial: It is customary in many Islamic traditions for a family member to stay with the body, providing comfort and ensuring the body is treated with respect. However, the nurse should ensure this is done within the hospital's policies and in a safe, culturally sensitive manner. This practice should be respected, but it is not the immediate priority for the nurse during postmortem care.
C) Allow a family member to stay with the client’s body for 8hr: While some Islamic traditions may involve family members staying with the body, the nurse should adhere to the specific wishes of the family and the institution's policies. The 8-hour duration is not a specific religious requirement, and the focus should be on providing respectful, appropriate care and ensuring the family’s wishes are honored within the hospital's guidelines.

D) Position the client’s head northward: In Islamic traditions, the body is positioned with the head facing toward Mecca, not northward. Positioning the head in a direction other than toward Mecca would not align with the cultural practices of Islam regarding postmortem care. Therefore, this action would not be appropriate.

A. Bran muffin B. Tomato juice C. Puffed rice cereal D. Cottage cheese

Correct Answer is A

Explanation

A) Bran muffin:
Bran is high in fiber, which is beneficial for managing constipation. Fiber helps to promote bowel movements by adding bulk to stool and improving gut motility. A bran muffin is an excellent choice for a client with constipation because it is rich in insoluble fiber, which is particularly effective in relieving constipation.

B) Tomato juice:
While tomato juice can provide some vitamins and nutrients, it is low in fiber, which is essential for managing constipation. For constipation relief, it is better to choose foods high in fiber, such as whole grains, fruits, and vegetables.

C) Puffed rice cereal:
Puffed rice cereal is low in fiber, making it an unsuitable choice for someone with constipation. Although it may provide some calories, it does not offer the beneficial fiber that can help relieve constipation.

D) Cottage cheese:
Cottage cheese is low in fiber and high in protein, but it does not contribute to bowel regularity. For constipation management, it is crucial to choose foods that are high in fiber, like fruits, vegetables, and whole grains, rather than low-fiber foods like cottage cheese.

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