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 A

Explanation

Choice A: Troponin I is a laboratory test that the nurse should anticipate the provider to prescribe. Troponin I is a protein that is released into the blood when the heart muscle is damaged. Troponin I levels are elevated in clients who have acute myocardial infarction (AMI), which is a heart atack caused by a blockage of blood ﬂow to the heart. Chest pressure and shortness of breath are common signs and symptoms of AMI. Troponin I is a specific and sensitive marker of cardiac injury and can help diagnose AMI and guide treatment.

Choice B: Aspartate aminotransferase (AST) is not a laboratory test that the nurse should anticipate the provider to prescribe. AST is an enzyme that is found in various tissues, such as the liver, heart, skeletal muscle, and kidneys. AST levels are elevated in clients who have liver damage, hepatitis, cirrhosis, or alcohol abuse. AST levels can also be elevated in clients who have AMI, but they are not as specific or sensitive as troponin I. AST is not a reliable indicator of cardiac injury and can be inﬂuenced by other factors.

Choice C: B-type natriuretic peptide (BNP) is not a laboratory test that the nurse should anticipate the provider to prescribe. BNP is a hormone that is secreted by the heart when it is stretched or overloaded. BNP levels are elevated in clients who have heart failure, which is a condition in which the heart cannot pump enough blood to meet the

body's needs. Shortness of breath can be a sign of heart failure, but chest pressure is not. BNP is not a specific or sensitive marker of cardiac injury and can be inﬂuenced by other factors.

Choice D: Lipase is not a laboratory test that the nurse should anticipate the provider to prescribe. Lipase is an enzyme that is produced by the pancreas and helps digest fats. Lipase levels are elevated in clients who have pancreatitis, which is an inﬂammation of the pancreas. Pancreatitis can cause abdominal pain, nausea, vomiting, and fever. Chest pressure and shortness of breath are not signs of pancreatitis. Lipase is not a specific or sensitive marker of cardiac injury and has no relation to AMI.

A. Remove both of the elastic bandages from the leg. B. Discharge the client. C. Obtain a prescription for the appropriate anti-venom. D. Obtain a prescription for pain medication.

Correct Answer is C

Explanation

Choice A: Removing the elastic bandages is not recommended. These bandages help slow the spread of venom by compressing the lymphatic vessels. Removing them could worsen the envenomation.

Choice B: This is incorrect. The nurse should not discharge the client, as they may develop serious complications from the snake bite, such as swelling, bleeding, infection, or shock. The client should be monitored closely and treated accordingly.

Choice C: This is the correct action. Antivenom treatment is crucial for serious snake envenomation. The sooner it can be administered, the better the outcome.

Choice D: While pain management is important, it is not the priority in this situation. Antivenom takes precedence over pain medication.

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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 reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe?

Correct Answer is A

Explanation

A nurse in an emergency department is assessing a client who was biten on the left leg by a poisonous snake. The client has placed elastic bandages snugly above and below the bite marks and is in no apparent distress. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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