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?

Option 1:
A. Perform immediate wound care and dressing on the occipital wound.

Option 2:
B. Administer high-flow oxygen and prioritize the client for immediate evacuation.

Option 3:
C. Begin chest compressions and initiate CPR.

Option 4:
D. Assess for other less severe injuries before providing care.

Answer 1

The nurse should administer high-flow oxygen and prioritize the client for immediate evacuation due to the critical signs indicating severe trauma and the need for urgent medical care.

Step-by-step explanation:

The nurse should take Option 2: Administer high-flow oxygen and prioritize the client for immediate evacuation. The patient exhibits several critical signs: a very low respiratory rate, agonal breathing pattern, delayed capillary refill time, and nonresponsiveness to painful stimuli. These symptoms indicate severe trauma and a possible traumatic brain injury, which require swift and decisive action to manage the patient's airway, breathing, and circulation. Immediate wound care is not the priority when a patient has such critical vital signs and requires urgent evacuation to a medical facility for advanced care. Performing chest compressions and CPR (Option 3) is not indicated unless the patient is in cardiac arrest, which is not clear from the description provided. Assessing less severe injuries or performing immediate wound care (Options 1 and 4) should not take precedence over managing life-threatening conditions and preparing for rapid transport.