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 C

Explanation

A) Rubber duck:
A rubber duck may be a suitable toy for a 2-month-old infant during bath time, but it is not considered the most developmentally appropriate for this age. At 2 months, infants are beginning to focus their vision on objects but have limited ability to manipulate toys. Toys such as a rubber duck do not provide the most stimulating developmental experience for an infant at this age.
B) Nesting cups:
Nesting cups are not the most appropriate for a 2-month-old infant. At this stage of development, babies are still in the early stages of hand-eye coordination and grasping skills. Nesting cups are more suitable for older infants (around 6-9 months) who are beginning to explore stacking, nesting, and grasping objects with more precision.
C) Crib mobile:
A crib mobile is an excellent developmentally appropriate toy for a 2-month-old infant. At this age, infants are developing visual tracking skills and are attracted to high-contrast patterns or moving objects. A crib mobile offers visual stimulation and can help an infant focus their eyes on objects, encouraging visual tracking and early sensory development. It is also safe for use in the crib environment.
D) Plastic keys:
Plastic keys can be a good toy for older infants as they begin developing their grasping and mouthing skills, but a 2-month-old infant is not yet able to hold objects or bring them to their mouth with coordination. Toys like these would not offer much benefit in terms of developmental stimulation at this age.

A. The client's meal tray includes ice cream with fresh fruit. B. The client is assigned to a room with negative airflow. C. The client has artificial flowers in the room. D. The client's meal tray contains hard boiled eggs.

Correct Answer is A

Explanation

A) The client's meal tray includes ice cream with fresh fruit: Fresh fruit poses a risk to a neutropenic client because it may harbor harmful bacteria or fungi, which could lead to an infection. Neutropenic clients have a weakened immune system and are more vulnerable to infections, so it is essential to avoid raw or unwashed fruits that can carry harmful pathogens.

B) The client is assigned to a room with negative airflow: A room with negative airflow is a precautionary measure used to prevent the spread of airborne pathogens, particularly for clients with compromised immune systems. This would help reduce the risk of infection by keeping potentially harmful microorganisms from circulating into the room.

C) The client has artificial flowers in the room: While artificial flowers may not pose an immediate risk for infection, they can accumulate dust and other particles that may contribute to a less clean environment. However, they are not as significant a risk factor as the presence of fresh fruits, which can carry live microorganisms capable of causing infections in neutropenic patients.

D) The client's meal tray contains hard boiled eggs: Hard boiled eggs are generally considered safe for neutropenic clients as long as they are properly cooked and stored. Eggs are not a known source of infection in this context, especially when they are cooked and handled properly.

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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?

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