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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is: C. Continue the rate at 125 mL/hr.
Choice A: Slow the rate to 50 mL/hr
Slowing the IV fluid rate to 50 mL/hr is not appropriate for a patient with a head injury. Adequate fluid management is crucial to maintain cerebral perfusion pressure and prevent secondary brain injury. Reducing the rate to 50 mL/hr could lead to hypovolemia, which might decrease cerebral perfusion and worsen the patient’s condition.
Choice B: Slow the rate to 20 mL/hr
Slowing the IV fluid rate to 20 mL/hr is even less appropriate. Such a low rate would likely result in significant hypovolemia, severely compromising cerebral perfusion pressure. This could exacerbate the patient’s head injury by reducing the blood flow to the brain, leading to further damage.
Choice C: Continue the rate at 125 mL/hr
Continuing the rate at 125 mL/hr is appropriate. This rate helps maintain euvolemia, which is essential for ensuring adequate cerebral perfusion pressure in patients with head injuries. Maintaining a stable fluid rate helps prevent both hypovolemia and hypervolemia, both of which can negatively impact intracranial pressure and cerebral perfusion.
Choice D: Increase the rate to 250 mL/hr
Increasing the IV fluid rate to 250 mL/hr is not recommended. Overhydration can lead to increased intracranial pressure, which can be detrimental to a patient with a head injury. Excessive fluid administration can cause cerebral edema, worsening the patient’s condition.

A. Weakened gag reﬂex B. Hyperthermia C. Absence of bowel sounds D. Paralysis E. Polyuria F. Hypotension

Correct Answer is ["A","C","D","F"]

Explanation

Choice A: A cervical spinal cord injury can impair the function of cranial nerves, leading to a weakened gag reflex and an increased risk of aspiration.

Choice B:Patients with spinal cord injuries are more likely to experience poikilothermia (difficulty regulating body temperature), but this often results in hypothermia, not hyperthermia, due to the loss of autonomic temperature control.

Choice C:Spinal shock, which often follows a spinal cord injury, can cause decreased or absent bowel sounds due to a temporary loss of autonomic function and decreased peristalsis.

Choice D:Depending on the level and severity of the injury, paralysis can occur, affecting motor function below the injury site. A cervical spinal cord injury may lead to quadriplegia (tetraplegia).

Choice E:Clients with spinal cord injuries are more likely to experience urinary retention, rather than polyuria, due to loss of bladder control and autonomic dysfunction. A foley catheter may be needed initially, followed by intermittent catheterization.

Choice F:Neurogenic shock, a potential complication of cervical spinal cord injuries, can cause hypotension due to the loss of sympathetic nervous system control over blood vessel tone, leading to vasodilation and bradycardia.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is caring for a client who sustained a head injury. The nurse notes the client's IV ﬂuids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?

Correct Answer is C

Explanation

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

Correct Answer is ["A","C","D","F"]

Explanation

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