A nurse is preparing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?

A) Check the client's pulse rate: While it is important to assess vital signs, the priority in this scenario is ensuring that the client’s airway is open and that they can breathe adequately. A pulse rate check can be performed after addressing the immediate respiratory needs.

B) Administer oxygen to the client: Administering oxygen is important for clients who are cyanotic and showing signs of respiratory distress. However, oxygen will not be effective if the airway is obstructed. The first priority is to ensure that the airway is open and clear, as this is the most immediate need for breathing.

C) Establish a patent airway for the client: The most immediate priority is to ensure that the client has a patent airway. Cyanosis and a decreased respiratory rate with shallow respirations indicate that the client is likely unable to get enough oxygen, possibly due to an obstruction or inadequate airway. Once the airway is secured, other interventions such as administering oxygen can follow.

D) Place a pulse oximeter on the client's finger: While measuring oxygen saturation is important, the priority action is to ensure that the client’s airway is open first. If the client is cyanotic and showing signs of respiratory distress, the nurse must address the airway immediately before assessing the pulse oximeter reading, as it may not provide accurate data without a patent airway.

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.