Question

A nurse on the scene following a mass casualty explosion is triaging a client who has a large, open occipital wound and the following findings: respiratory rate 6/min, agonal pattern; capillary refill time 4.5 seconds; nonresponsive to painful stimuli. Which of the following actions should the nurse take?

A.) Apply a tourniquet proximal to the wound.

B.) Administer an intravenous pain medication.

C.) Assess and manage the airway.

D.) Perform a detailed neurological examination.

Answer 1

The nurse should immediately assess and manage the airway, which involves clearing the airway and potentially providing assisted ventilation, as this is the critical and life-threatening issue at hand. (Option c)

Step-by-step explanation:

The nurse should prioritize airway management, as this patient has a significantly decreased respiratory rate with an agonal pattern, indicating a need for immediate intervention. The correct action that should be taken by the nurse is C.) Assess and manage the airway. Management may include clearing the airway and providing assisted ventilation. Tourniquets (Option A) are used for extremity hemorrhage, which is not indicated here. Administering pain medication intravenously (Option B) is not a priority given the patient's nonresponsive state and critical airway status. Furthermore, a detailed neurological examination (Option D) is not a priority during initial triage when life-threatening conditions must first be addressed.

Rapid assessment of neurological function is crucial in an emergency because it helps to determine the severity and localization of nervous system damage, which informs treatment priorities. This is especially necessary when a stroke is suspected, as quick intervention can significantly affect the outcome. In cases of trauma, such as the one described, the immediate threat to life, such as severe airway compromise, should always be addressed first before assessing neurological function or administering medications.