The nurse is first on the scene following a multivehicle accident. After activating emergency services and verifying the safety of the scene, the nurse begins the triage process. The first patient is unconscious and not breathing. Which action does the nurse take first?

Perform a chin-tilt maneuver. The patient who is unconscious and apneic after a trauma should have the airway repositioned with a chin-tilt maneuver and be reassessed. If the patient is still apneic, the nurse should place a black triage tag on the patient and move on to the next victim. If the patient begins to breathe with airway repositioning, the nurse determines respiratory rate and assesses for a radial pulse. Assessing the patient’s pupils can be helpful to assess for brain injury, but it is not the nurse’s first action.

The nurse is first on the scene following a multivehicle accident...

Category: Management of Care
Difficulty: 9

Topics: Cardiovascular Communication & Documentation Delegation, Prioritization and Leadership Assessment Crisis Management Health Care Ethics, Law, and Policy Health Promotion Health Screening Respiratory

Want help? View the answer with rationale.

Additional Management of Care Questions

The patient with end stage renal disease is on the transplant waiting list for a kidney. The nurse is aware this patient’s wait time will depend on which factors? Select all that apply.

Question Type: Multiple Choice - Select All
Difficulty: 4

The student nurse prepares to document in the nursing note, “Patient is in bad mood today.” The preceptor corrects the student nurse to document which statement instead?

Question Type: Multiple Choice - Select One
Difficulty: 3

After receiving a dose of antibiotics, a 34-year-old man develops an itchy rash, throat swelling, shortness of breath, lightheadedness, and hypotension. Which of the following is the best next step?

Question Type: Multiple Choice - Select One
Difficulty: 7

Show Calculator

Want help? View the answer with rationale.

Rationale

Additional Management of Care Questions

Nursing Careers

Nursing Degrees

NCLEX