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 C

Explanation

A) Occasional small clots in the urine:
Occasional small clots can be expected after a transurethral resection of the prostate (TURP) due to the surgical trauma to the prostate and surrounding tissues. However, any change in the nature or frequency of clots, or if they become larger, should be reported, but small clots are not immediately concerning in the early postoperative period.

B) Urine output of 300 mL over 8 hr:
This urine output is within a reasonable range. While urine output may be initially monitored closely after TURP, a volume of 300 mL over 8 hours does not constitute a concerning finding. It may be less than expected, but it is not an emergency. The nurse should continue to monitor urine output, but this is not immediately concerning unless the client has a significantly reduced or absent output.

C) Dark red urine:
Dark red urine is a concerning finding as it may indicate excessive bleeding or hemorrhage, especially within the first 24 hours after TURP. While some initial hematuria (blood in the urine) is common, the urine should not remain dark red or worsen. This could indicate active bleeding or a clot obstructing the urinary flow, which requires immediate intervention and reporting to the healthcare provider to prevent complications.

D) Frequent urge to urinate:
A frequent urge to urinate is not an unusual finding following TURP, as the bladder may be irritated due to the catheter or residual inflammation from the surgery. While it is a discomforting symptom, it is typically not an immediate concern and often resolves as the healing process progresses. However, persistent or painful urination may require further evaluation.

A. Believes the death is punishment for bad behavior B. Recognizes the parent will never wake up C. Understands that everyone dies eventually D. Expresses curiosity about the funeral service

Correct Answer is A

Explanation

A) Believes the death is punishment for bad behavior: Preschoolers, typically ages 3 to 5, often engage in magical thinking and may believe that death is a result of their own actions or bad behavior. They may see death as a punishment for something they did wrong, as they have difficulty understanding the permanence and inevitability of death. This egocentric thinking is typical for their developmental stage.

B) Recognizes the parent will never wake up: Preschoolers may not yet fully comprehend the permanence of death. They may think the deceased parent will eventually wake up or return. This belief reflects their limited understanding of death, which they may view as reversible or temporary, especially if they haven't encountered death before.

C) Understands that everyone dies eventually: Preschoolers do not generally have the cognitive ability to grasp the concept that everyone dies eventually. This understanding develops later, typically during the concrete operational stage of development (around age 7 or 8), when children begin to understand death as permanent and universal.

D) Expresses curiosity about the funeral service: While some preschoolers may express curiosity about events like a funeral, it is more likely that their curiosity would be centered on simple, tangible aspects of death (such as asking questions about where the person went or what happens to their body) rather than the ceremony itself. At this stage, children may not fully understand the cultural or symbolic meanings of a funeral service.

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

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