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 dabigatran does not affect the electrical activity of the heart or the conduction system. It does not slow down the ventricular response to the atrial impulses.
Choice B Reason: This is incorrect because dabigatran does not dissolve existing clots in the bloodstream. It only prevents new clots from forming.
Choice C Reason: This is correct because dabigatran reduces the risk of stroke in clients who have atrial fibrillation by preventing clot formation and reducing blood viscosity. Dabigatran is an anticoagulant medication that prevents the formation of blood clots in the heart and blood vessels. Atrial fibrillation is a condition where the atria beat irregularly and rapidly, which can cause blood to pool and clot in the heart chambers. These clots can travel to the brain and cause a stroke. Dabigatran reduces the risk of stroke by preventing clot formation and reducing blood viscosity.
Choice D Reason: This is incorrect because dabigatran does not restore normal sinus rhythm in clients who have atrial fibrillation. It does not affect the heart rate or rhythm.
Correct Answer is D
Explanation
Choice A: Carvedilol is not a medication that interacts with contrast material and places the client at risk for acute kidney injury. Carvedilol is a beta-blocker that lowers blood pressure and heart rate by blocking the effects of adrenaline on the heart and blood vessels. Carvedilol does not affect kidney function or contrast excretion, but it can cause hypotension, bradycardia, or heart failure in some clients.
Choice B: Nitroglycerin is not a medication that interacts with contrast material and places the client at risk for acute kidney injury. Nitroglycerin is a vasodilator that relaxes the smooth muscles of the blood vessels and increases blood flow to the heart. Nitroglycerin does not affect kidney function or contrast excretion, but it can cause hypotension, headache, or flushing in some clients.
Choice C: Atorvastatin is not a medication that interacts with contrast material and places the client at risk for acute kidney injury. Atorvastatin is a statin that lowers cholesterol levels by inhibiting an enzyme that produces cholesterol in the liver. Atorvastatin does not affect kidney function or contrast excretion, but it can cause liver damage, muscle pain, or rhabdomyolysis in some clients.
Choice D: Metformin is a medication that interacts with contrast material and places the client at risk for acute kidney injury. Metformin is an oral antidiabetic drug that lowers blood glucose levels by decreasing hepatic glucose production and increasing insulin sensitivity. Metformin can accumulate in the kidneys and cause lactic acidosis, a life-threatening condition characterized by high levels of lactic acid in the blood. Contrast material can worsen kidney function and increase the risk of lactic acidosis in clients taking metformin. Therefore, metformin should be discontinued before and after the procedure as prescribed.
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