A client who was involved in a motor vehicle collision while riding a motorcycle without wearing a helmet, is brought the emergency department (ED) by emergency medical services (EMS). Which assessment should the nurse obtain first?

Degree of pain using a 10 point scale.

Pulse and blood pressure.

Balance and coordination.

Bilateral pupillary reaction to light.

Answer and Explanation

The Correct Answer is B

A. Degree of pain using a 10-point scale. Pain assessment is important, but it is not the priority in an emergency trauma situation. Clients involved in motor vehicle collisions (MVCs) without a helmet are at high risk for life-threatening injuries, including hemorrhage and shock. The nurse must first assess vital signs to determine hemodynamic stability.
B. Pulse and blood pressure. The primary concern in trauma patients is circulation and perfusion. Assessing pulse and blood pressure helps determine if the client is experiencing shock, hemorrhage, or traumatic brain injury (TBI)-related autonomic dysfunction. In trauma resuscitation, the ABCs (Airway, Breathing, Circulation) guide assessment priorities, making circulatory status the first concern after ensuring airway patency.
C. Balance and coordination. A neurological assessment for balance and coordination is not a priority in a critically injured trauma patient. Severe injuries, including intracranial hemorrhage, cervical spine trauma, or internal bleeding, must be ruled out before assessing fine motor function.
D. Bilateral pupillary reaction to light. Pupillary response is part of a neurological assessment and is crucial in identifying traumatic brain injury. However, vital signs must be assessed first to determine hemodynamic stability, as untreated shock or hemorrhage can lead to rapid deterioration or death.

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Correct Answer is C

Explanation

A. Place a cooling blanket on the client. A temperature of 100°F (37.8°C) is only mildly elevated and does not require active cooling. The priority concern is hemodynamic instability due to hypovolemia, not fever management. Cooling blankets are typically used for high fevers (≥ 102°F or 38.9°C).
B. Administer an antipyretic agent. While fever may indicate postoperative infection or inflammatory response, the client’s most critical issue is hypotension and low urine output, suggesting hypovolemia or early shock. Treating the underlying cause (fluid loss) is more urgent than giving an antipyretic.
C. Give a 500 mL IV fluid bolus challenge. The client has tachycardia (132 bpm), hypotension (88/65 mm Hg), and oliguria (10 mL/hour), all of which suggest hypovolemic shock, a common postoperative complication. A fluid bolus (typically 500–1000 mL of isotonic crystalloid such as normal saline or lactated Ringer’s) is the first-line treatment to restore intravascular volume, improve blood pressure, and increase urine output.
D. Titrate IV vasopressor for systolic less than 80. Vasopressors (e.g., norepinephrine) are not the first-line treatment for hypovolemic shock. Fluids should be administered first to correct volume loss before considering vasopressors. If hypotension persists despite adequate fluid resuscitation, vasopressors may be initiated.

A. Provide a bedside table for client to lean across. B. Place bed in the reverse Trendelenburg position. C. Encourage bed rest until analgesic takes effect. D. Raise the head of the bed to a 90 degree angle.

Correct Answer is A

Explanation

A. Provide a bedside table for the client to lean across. Clients with acute pancreatitis often experience severe epigastric pain that radiates to the back. Leaning forward helps reduce pressure on the inflamed pancreas and relieves pain by minimizing peritoneal irritation. Providing a bedside table allows the client to rest in a comfortable, supported position, improving pain management without additional interventions.
B. Place bed in the reverse Trendelenburg position. Reverse Trendelenburg elevates the head and lowers the feet, which does not specifically relieve pain associated with pancreatitis. The client instinctively leans forward for relief, and adjusting the bed position would not provide the same benefit. This intervention does not directly address the underlying cause of discomfort.
C. Encourage bed rest until analgesic takes effect. Although pain control is essential, keeping the client in a supine or bedrest position can increase abdominal pressure and worsen discomfort. Allowing the client to assume a comfortable position enhances the effectiveness of analgesics and prevents unnecessary distress. Pain relief strategies should focus on both pharmacologic and positioning interventions.
D. Raise the head of the bed to a 90-degree angle. Elevating the head of the bed can improve breathing and reduce reflux, but it does not provide the same pressure relief as leaning forward. Sitting upright without forward support does not effectively relieve peritoneal irritation from pancreatic inflammation. Providing a bedside table supports proper positioning and enhances comfort.

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A client who was involved in a motor vehicle collision while riding a motorcycle without wearing a helmet, is brought the emergency department (ED) by emergency medical services (EMS). Which assessment should the nurse obtain first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client diagnosed with pancreatitis reports severe epigastric pain. After administering a narcotic analgesic, the client insists on Tip sitting up and leaning forward. Which action should the nurse implement?

Correct Answer is A

Explanation

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