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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) "I will get you information about some head-covering options."
This response acknowledges the client's concern about hair loss and provides a supportive and proactive solution. Many chemotherapy clients experience hair loss, and offering resources for head coverings shows empathy while helping them cope with the anticipated changes in appearance. It demonstrates the nurse's willingness to assist the client with emotional and physical challenges related to treatment.
B) "Let’s discuss this when we have more time."
Delaying the discussion about hair loss is not ideal. It dismisses the client’s current concern and may make the client feel like their feelings are not a priority. Hair loss can be a significant emotional challenge, and the nurse should address it in a timely and compassionate manner rather than postponing the conversation.
C) "I can’t imagine how difficult it would be to lose my hair."
While this response is empathetic, it focuses on the nurse's feelings instead of addressing the client's concern. It is important to maintain a client-centered approach and focus on the client's needs. The nurse should offer concrete support or information, such as head-covering options, rather than expressing personal emotions that may not be helpful to the client.
D) "I wouldn’t worry about this right now. Let's focus on your chemotherapy."
This response dismisses the client's concern about hair loss, which can be a significant issue for many clients starting chemotherapy. Minimizing the concern or suggesting it is not worth discussing at this time may make the client feel unheard or undervalued. It’s important to acknowledge the client’s worries and provide support for them to manage the emotional impacts of chemotherapy.
Correct Answer is B
Explanation
A) Prolonged PT/INR:
A prolonged PT/INR is typically associated with liver dysfunction or clotting disorders. While pancreatitis can lead to complications like bleeding, it does not directly cause a prolonged PT/INR. In the case of pancreatitis, the main concerns are related to enzymes, fluid and electrolyte imbalances, and potential organ dysfunction, but clotting issues are not a primary diagnostic feature.
B) Elevated lipase:
This is the most characteristic lab finding in pancreatitis. Lipase is an enzyme produced by the pancreas, and its levels rise significantly when the pancreas is inflamed. Elevated lipase levels are a key diagnostic indicator of pancreatitis, often seen alongside elevated amylase levels. This finding helps confirm the diagnosis and monitor the severity of the condition.
C) Decreased albumin:
Decreased albumin levels are typically seen in conditions that affect liver function, kidney disease, or malnutrition. While pancreatitis can lead to some degree of malnutrition or fluid shifts, a decreased albumin level is not a specific or expected finding in pancreatitis itself. The focus is more on enzyme levels and possible complications like hypocalcemia or hyperglycemia.
D) Elevated ammonia:
Elevated ammonia levels are generally indicative of liver dysfunction or hepatic encephalopathy, which occurs in severe liver disease. While pancreatitis can cause systemic complications, an elevated ammonia level is not a typical lab finding associated with pancreatitis. Ammonia is more commonly monitored in cases of liver failure or cirrhosis.
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