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 B

Explanation

A) Rigid abdomen: A rigid abdomen is more commonly associated with conditions like placental abruption or uterine rupture, where there is significant internal bleeding and trauma to the uterine wall. It is not a typical finding in placenta previa, where bleeding is typically present without uterine rigidity.

B) Bright red vaginal bleeding: Bright red vaginal bleeding is the most characteristic finding in placenta previa. The condition occurs when the placenta is abnormally located in the lower part of the uterus, covering or being near the cervix. This leads to painless, bright red vaginal bleeding, which is often seen in the second or third trimester. The bleeding results from the placenta's location as the uterus expands.

C) Persistent uterine contractions: Persistent uterine contractions are more often associated with preterm labor or placental abruption, not placenta previa. While contractions can occur in placenta previa, they are not the primary or most expected symptom. The hallmark of placenta previa is bleeding, rather than contractions.

D) Increased fetal movement: Fetal movement is not typically altered by placenta previa. In some cases, the location of the placenta may affect the feeling of fetal movement, especially if the placenta is anterior, but increased fetal movement is not a specific finding associated with placenta previa. The focus should be on bleeding and uterine stability.

A. Temperature B. Blood pressure C. Pain D. Urine output E. Heart rate F. Respiratory status G. Sodium level H. Mental confusion I. Serum amylase level J. Cold, clammy skin

Correct Answer is ["A","B","E","F","H","J"]

Explanation

A. Temperature: The client’s temperature increased from 37.2°C (99°F) to 38.9°C (102°F), indicating a possible infection or systemic inflammatory response. Fever in acute pancreatitis can suggest worsening inflammation, infection, or sepsis and should be reported immediately.
B. Blood pressure: The client's blood pressure dropped from 126/78 mmHg to 92/48 mmHg, indicating hypotension, which could be due to fluid shifts, systemic inflammation, or early shock. Immediate intervention is necessary to prevent hemodynamic instability.
C. Pain: While severe pain (rated 10/10) is expected in acute pancreatitis, it is not the most urgent concern requiring immediate reporting compared to hemodynamic instability and respiratory distress.
D. Urine output: The current urine output is not critically low (50-60 mL/hr), but continued monitoring is necessary. However, it is not an immediate life-threatening concern requiring urgent reporting.
E. Heart rate: The client’s heart rate increased from 90/min to 132/min, which is a significant tachycardia. This suggests compensatory shock, fluid loss, or worsening systemic inflammation and requires immediate provider notification.
F. Respiratory status: The respiratory rate increased from 18/min to 32/min, and oxygen saturation dropped to 88% on 3 L/min O₂. This suggests respiratory compromise, possibly due to worsening systemic inflammation, pleural effusion, or acute respiratory distress syndrome (ARDS).
G. Sodium level: The sodium level remains within the normal range (142 mEq/L; normal: 136-145 mEq/L), so it does not require immediate reporting.
H. Mental confusion: The client, who was alert on Day 1, is now disoriented. This change in mental status can indicate worsening systemic inflammation, hypoxia, or impending shock, requiring urgent intervention.
I. Serum amylase level: While elevated (498 units/L), this is expected in pancreatitis and does not require immediate notification unless there is a sudden drastic change.
J. Cold, clammy skin: This is a sign of poor perfusion and possible shock. It indicates worsening hemodynamic instability and requires immediate intervention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is ["A","B","E","F","H","J"]

Explanation

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