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 A

Explanation

A) "My baby will receive the rotavirus immunization orally.":
This statement is correct. The rotavirus vaccine is given orally in two or three doses depending on the specific vaccine used (Rotarix or RotaTeq). The vaccine is administered in the mouth and helps protect against rotavirus infections, which can cause severe diarrhea in infants and young children.

B) "I should expect my baby to have a high fever for 24 hours after an immunization.":
This statement is incorrect. While it is common for infants to experience mild side effects after immunizations, such as a low-grade fever or irritability, a high fever is not typically expected. If the baby develops a high fever (above 100.4°F), the guardian should seek advice from the healthcare provider, as it could indicate a reaction or infection.

C) "I should not feed my baby anything for hours prior to an immunization.":
This statement is incorrect. There is no need to withhold feeding before an immunization, and the baby should be fed as usual. In fact, feeding the infant before the appointment may help comfort them and reduce stress during the visit.

D) "My baby will receive three doses of the meningococcal immunization before kindergarten.":
This statement is incorrect. The meningococcal vaccine is typically administered starting at age 11, with a second dose given at age 16. For infants and young children, the vaccine is not part of the routine immunization schedule. Meningococcal vaccination before kindergarten is not recommended for infants at 2 months of age.

A. Client report of muscle spasms of the left leg B. One fingerbreadth of space between the cast and the skin C. Diminished pulses on the affected extremity D. Ecchymosis on the inner left thigh

Correct Answer is C

Explanation

A) Client report of muscle spasms of the left leg: Muscle spasms are common in clients with a cast, especially if the muscle is restricted for an extended period. While muscle spasms can be uncomfortable, they are not immediately life-threatening. The nurse should still address the discomfort but it does not take priority over other potential issues like circulation.
B) One fingerbreadth of space between the cast and the skin: A small amount of space between the cast and the skin can be normal and is typically observed in a well-applied cast. However, this finding alone does not indicate an immediate concern unless other signs such as swelling or impaired circulation are noted.

C) Diminished pulses on the affected extremity: Diminished pulses are a priority concern. This may indicate compromised circulation, which can lead to serious complications such as tissue ischemia or compartment syndrome. The nurse should immediately assess the severity of the circulation problem, as any signs of compromised blood flow require prompt intervention to prevent permanent damage or loss of limb function.

D) Ecchymosis on the inner left thigh: Ecchymosis or bruising on the inner thigh can be a normal consequence of trauma or injury related to the reason for the cast. While it is important to monitor for any changes in the condition, ecchymosis itself is not immediately life-threatening or urgent compared to potential circulation issues.

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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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