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

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