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?
Place a black tag on the client’s upper body and atempt to help the next client in need.
Start CPR
Place a red tag on the client’s upper body and obtain immediate help from other personnel.
Reposition the client's upper airway a second time before assessing his respirations.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because the client's best motor response is 5, which means he can localize pain, not follow commands.
Choice B Reason: This is incorrect because the client's eye opening response is 3, which means he opens his eyes to pain, not to speech.
Choice C Reason: This is correct because the client's GCS score is 13, which indicates a severe impairment of consciousness. The GCS is a tool used to assess the level of consciousness of a person who has a head injury. The GCS score ranges from 3 to 15, with lower scores indicating lower levels of consciousness. A GCS score of 8 or less indicates coma. The client's GCS score is 3 + 5 + 5 = 13, which is above the coma threshold, but still indicates a severe impairment of consciousness. The other choices are not consistent with the client's GCS score.
Choice D Reason: This is incorrect because the client's best verbal response is 5, which means he can orient himself to person, place, and time, not that he is unable to make vocal sounds.
Correct Answer is A
Explanation
Choice A: Fatigue is a manifestation that the nurse should identify as indicating the client is hypokalemic. Hypokalemia is a condition in which the blood potassium level is lower than normal, usually due to excessive loss of potassium through urine, sweat, or vomiting. Potassium is an electrolyte that is essential for nerve and muscle function, especially for the heart. Hypokalemia can cause muscle weakness, cramps, and fatigue, as well as cardiac arrhythmias and dysrhythmias.
Choice B: Dyspnea is not a manifestation that the nurse should identify as indicating the client is hypokalemic. Dyspnea is a sensation of difficulty breathing or shortness of breath. Dyspnea can be caused by various conditions, such as asthma, chronic obstructive pulmonary disease (COPD), pneumonia, or pulmonary edema. Dyspnea is not directly related to hypokalemia, but it can be a sign of heart failure, which can cause fluid accumulation in the lungs and impair gas exchange.
Choice C: Oliguria is not a manifestation that the nurse should identify as indicating the client is hypokalemic. Oliguria is a reduced urine output, usually less than 400 mL per day or 30 mL per hour. Oliguria can be caused by various conditions, such as dehydration, kidney failure, urinary tract obstruction, or shock. Oliguria is not directly related to hypokalemia, but it can be a sign of kidney damage or impairment, which can affect electrolyte balance and fluid volume.
Choice D: Pitting edema is not a manifestation that the nurse should identify as indicating the client is hypokalemic. Pitting edema is a swelling of the tissues that leaves an indentation when pressed with a finger. Pitting edema can be caused by various conditions, such as venous insufficiency, lymphedema, liver cirrhosis, or malnutrition. Pitting edema is not directly related to hypokalemia, but it can be a sign of heart failure, which can cause fluid retention and overload in the body.
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