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 Reason: This is correct because the carotid pulse is the most accessible and reliable pulse to check during CPR for an adult client. The carotid pulse is the most accessible and reliable pulse to check during CPR for an adult client. The carotid pulse is located on the side of the neck, near the trachea. The nurse should use two fingers to palpate the carotid pulse for at least 5 seconds and no more than 10 seconds.

Choice B Reason: This is incorrect because the popliteal pulse is located behind the knee and is not easily palpable during CPR.

Choice C Reason: This is incorrect because the radial pulse is located on the wrist and may not be detectable during CPR due to low blood pressure or peripheral vasoconstriction.

Choice D Reason: This is incorrect because the apical pulse is located on the chest and requires a stethoscope to auscultate. The nurse should not interrupt chest compressions or ventilations to listen to the apical pulse during CPR.

A. pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg B. pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg C. pH 7.50, HCO3- 26 mEq/L, PaCO2 50 mm Hg D. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg

Correct Answer is D

Explanation

Choice A Reason: This is incorrect because these values indicate respiratory alkalosis, which is caused by hyperventilation or excess loss of carbon dioxide (PaCO2). Respiratory alkalosis increases the blood pH and decreases the HCO3- level.

Choice B Reason: This is incorrect because these values indicate metabolic alkalosis, which is caused by excess intake or retention of bases or loss of acids. Metabolic alkalosis increases the blood pH and the HCO3- level.

Choice C Reason: This is incorrect because these values indicate respiratory acidosis, which is caused by hypoventilation or excess retention of carbon dioxide (PaCO2). Respiratory acidosis decreases the blood pH and increases the HCO3- level.

Choice D Reason: This is correct because these values indicate metabolic acidosis, which is a common complication of chronic kidney disease. These values indicate metabolic acidosis, which is a common complication of chronic kidney disease. Metabolic acidosis occurs when the kidneys are unable to excrete excess acids or retain enough bicarbonate (HCO3-), which is a base that buﬀers the blood pH. As a result, the blood pH decreases and becomes more acidic. The normal range for blood pH is 7.35 to 7.45, for HCO3- is 22 to 26 mEq/L, and for PaCO2 is 35 to 45 mm Hg.

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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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