A nurse in an emergency department is assisting with the care of a client who is unconscious and has trauma to multiple systems following a motor vehicle crash. Which of the following actions should the nurse take first?
Airway protection
Stabilizing cardiac arrhythmias
Preventing musculoskeletal disability
Decreasing intracranial pressure
The Correct Answer is A
Choice A reason: This action is correct because airway protection is the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's airway patency, breathing, and oxygenation, and intervene as needed to secure and maintain the airway. The nurse should also monitor the client for signs of aspiration, bleeding, or obstruction, and suction the airway as needed.
Choice B reason: This action is incorrect because stabilizing cardiac arrhythmias is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's circulation, blood pressure, and pulse, and intervene as needed to treat any arrhythmias, shock, or hemorrhage. However, this is not a priority over the client's airway, which is essential for survival.
Choice C reason: This action is incorrect because preventing musculoskeletal disability is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's mobility, sensation, and alignment, and intervene as needed to prevent or treat any fractures, dislocations, or nerve injuries. However, this is not a priority over the client's airway, which is essential for survival.
Choice D reason: This action is incorrect because decreasing intracranial pressure is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's level of consciousness, pupillary response, and neurological status, and intervene as needed to prevent or treat any increased intracranial pressure, cerebral edema, or brain injury. However, this is not a priority over the client's airway, which is essential for survival.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Genetics is a nonmodifiable risk factor for disease because it is determined by the inherited traits from the parents. Genetics can influence the susceptibility, severity, and progression of certain diseases, such as cancer, diabetes, or cardiovascular disease. The nurse cannot change the client's genetic makeup, but can help the client to manage their condition and prevent complications.
Choice B reason: Sunbathing is a modifiable risk factor for disease because it is influenced by the client's behavior and lifestyle. Sunbathing can increase the exposure to ultraviolet (UV) radiation, which can damage the skin cells and cause skin cancer, premature aging, or sunburn. The nurse can educate the client on the importance of sun protection, such as using sunscreen, wearing protective clothing, and avoiding peak hours of sun exposure.
Choice C reason: Smoking is a modifiable risk factor for disease because it is influenced by the client's behavior and lifestyle. Smoking can harm the lungs, heart, blood vessels, and other organs, and increase the risk of various diseases, such as chronic obstructive pulmonary disease (COPD), lung cancer, or coronary artery disease. The nurse can assist the client in quitting smoking, such as providing counseling, nicotine replacement therapy, or pharmacological interventions.
Choice D reason: Unhealthy diet is a modifiable risk factor for disease because it is influenced by the client's behavior and lifestyle. Unhealthy diet can lead to obesity, malnutrition, or metabolic disorders, and increase the risk of various diseases, such as diabetes, hypertension, or stroke. The nurse can advise the client on the benefits of a balanced diet, such as eating more fruits, vegetables, whole grains, lean proteins, and healthy fats, and limiting the intake of salt, sugar, and saturated fats.
Correct Answer is A
Explanation
Choice A: This is the correct answer. A portal is a secure online platform that enables clients to access their health information, communicate with their providers, request appointments, refill prescriptions, and more. This enhances client satisfaction, engagement, and empowerment.
Choice B: This is incorrect. Same day access to client health record is not an advantage of electronic documentation, but a requirement for any documentation system. Clients have the right to access their health information within a reasonable time frame, regardless of whether it is paper-based or electronic.
Choice C: This is incorrect. The increase of duplicate tests performed on client is not an advantage of electronic documentation, but a disadvantage. Duplicate tests can result from poor communication, lack of interoperability, or human error. Electronic documentation can help reduce duplicate tests by facilitating data sharing, standardizing formats, and alerting providers of previous tests.
Choice D: This is incorrect. Decrease in coordination of client care is not an advantage of electronic documentation, but a disadvantage. Coordination of client care is essential for ensuring quality, safety, and continuity of care. Electronic documentation can improve coordination of client care by allowing multiple providers to access and update the same information, enabling real-time collaboration, and providing decision support tools.
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