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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect. Anginal pain usually lasts less than 20 min and subsides with rest or medication. Pain that lasts longer than 20 min may indicate a myocardial infarction.
Choice B Reason: This is incorrect. Anginal pain usually responds to rest and organic nitrates, such as nitroglycerin. Pain that does not improve with these measures may indicate unstable angina or a myocardial infarction.
Choice C Reason: This is incorrect. Anginal pain is not affected by the position of the client. Pain that is relieved by sitting up may indicate pericarditis or pleurisy.
Choice D Reason: This is correct. Anginal pain is caused by a temporary imbalance between the oxygen demand and supply of the myocardium. Factors that increase the oxygen demand, such as exertion, anxiety, cold, or heavy meals, can trigger anginal pain.
Correct Answer is A
Explanation
The correct answer is: A. Elective cardioversion
Choice A reason:
Elective cardioversion is a medical procedure that is used to restore a normal heart rhythm in patients experiencing certain types of arrhythmias, including ventricular tachycardia (VT), when they are stable. It involves the delivery of a controlled electric shock to the heart, which is synchronized with the heart's electrical activity to convert the abnormal rhythm back to a normal sinus rhythm. This procedure is typically performed when VT is not causing hemodynamic instability and the patient is not in immediate danger.
Choice B reason:
Defibrillation is an emergency treatment for life-threatening cardiac arrhythmias, particularly ventricular fibrillation (VF) or pulseless ventricular tachycardia. It involves delivering a high-energy electric shock to the heart unsynchronized to the heart's electrical cycle, aiming to reset the heart's electrical state and allow it to reestablish an effective rhythm. In the scenario provided, where the patient is experiencing VT but not VF, defibrillation would not be the first line of action unless the VT deteriorates into VF or the patient becomes pulseless.
Choice C reason:
CPR, or cardiopulmonary resuscitation, is a lifesaving technique useful in many emergencies, including heart attack or near drowning, in which someone's breathing or heartbeat has stopped. In the case of VT, if the patient is conscious and has a pulse, CPR is not indicated. CPR would only be necessary if the patient's heart stops beating (cardiac arrest) as a result of the VT.
Choice D reason:
Radiofrequency catheter ablation is a procedure used to treat some types of arrhythmias, including VT, by destroying the area of heart tissue that is causing the abnormal heart rhythm. This treatment is generally considered when medication is ineffective or not tolerated, or in recurrent VT. It is not typically the first line of treatment in an acute setting where the patient is stable and experiencing VT.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today