A nurse is triaging victims of a multiple motor-vehicle crash. The nurse assesses a client trapped under a car who is apneic and has a weak pulse at 120/min. After repositioning his upper airway, the client remains apneic. Which of the following actions should the nurse take?

Choice A Reason: This is incorrect. Pulse and blood pressure findings are not reliable indicators of pain, as they can be influenced by many other factors, such as anxiety, medication, or underlying conditions. They are also not sensitive enough to detect changes in pain intensity or relief.

Choice B Reason: This is incorrect. Scheduled treatments and client illness are not relevant parameters for assessing pain, as they do not reflect the current pain experience of the client. They may provide some clues about the possible causes or sources of pain, but they do not measure the pain itself.

Choice C Reason: This is correct. A self-report pain rating scale is the most valid and reliable parameter for assessing pain, as it reflects the subjective perception of the client. The nurse should use a simple and appropriate scale, such as a numeric or visual analog scale, and ask the client to point to the number or picture that best represents their pain level.

Choice D Reason: This is incorrect. Behavioral indicators and affect are useful parameters for assessing pain, especially when the client has difficulty communicating verbally, but they are not the first choice. They are more subjective and variable than self-report, and they may be influenced by cultural or personal factors. They should be used in conjunction with self-report, not instead of it.

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.