A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care?

A client who has severe head injuries, respiratory rate 6/min, and is unresponsive

A client who has a simple fracture of the femur, multiple scratches on both legs, and is crying hysterically

A female who is pregnant at 20 weeks of gestation, has multiple cuts and abrasions, and is walking around

A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site

Answer and Explanation

The Correct Answer is D

Choice A Reason: This is incorrect because this client has signs of brain death, such as severe head injuries, low respiratory rate, and unresponsiveness. The nurse should tag this client as black, which means deceased or expectant.

Choice B Reason: This is incorrect because this client has non-life-threatening injuries, such as a simple fracture and scratches. The nurse should tag this client as green, which means minor or delayed care.

Choice C Reason: This is incorrect because this client has minor injuries and is able to walk around. The nurse should tag this client as green, which means minor or delayed care.

Choice D Reason: This is correct because this client has a life-threatening condition called tension pneumothorax, which requires immediate care. This client has a life-threatening condition called tension pneumothorax, which is caused by air leaking into the pleural space and compressing the lung and the heart. This can lead to respiratory failure, cardiac arrest, and death if not treated immediately. The hissing sound indicates that air is escaping from the lung through the wound. The nurse should tag this client as red, which means immediate care is needed.

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Correct Answer is A

Explanation

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.

A. Shortening of P-wave duration B. Restoration of QRS complex amplitude C. Reduction of T-wave amplitude D. Widening of the QRS complex

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because shortening of P-wave duration is not a sign of hyperkalemia or its reversal.

P-wave duration reﬂects the time it takes for the atria to depolarize and contract.

Choice B Reason: This is incorrect because restoration of QRS complex amplitude is not a sign of hyperkalemia or its reversal. QRS complex amplitude reﬂects the voltage or strength of the ventricular depolarization and contraction.

Choice C Reason: This is correct because the reduction of T-wave amplitude is a sign of hyperkalemia reversal. T-wave amplitude reﬂects the repolarization or recovery of the ventricles after contraction. Polystyrene sulfonate is a medication that lowers the serum potassium level by binding to it in the gastrointestinal tract and excreting it in the stool. High serum potassium level, or hyperkalemia, can cause cardiac arrhythmias and ECG changes, such as peaked T waves, prolonged PR interval, ﬂatened P waves, widened QRS complex, and ventricular fibrillation. By lowering the serum potassium level, polystyrene sulfonate can reverse these ECG changes and normalize the cardiac rhythm.

Choice D Reason: This is incorrect because the widening of the QRS complex is a sign of hyperkalemia, not its reversal. Widening of the QRS complex reﬂects the delay or impairment of ventricular depolarization and contraction.

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A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. If this medication is eﬀective, the nurse should expect which of the following changes on the client’s ECG?

Correct Answer is C

Explanation

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