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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Use of restraints is not included in the outcome category, but in the process category. The process category measures the nursing interventions and activities that affect the client's health outcomes. Use of restraints is a nursing intervention that can have negative effects on the client's physical and psychological wellbeing, such as injuries, infections, agitation, and depression.
Choice B reason: Client admissions is not included in the outcome category, but in the structure category. The structure category measures the characteristics and resources of the health care setting that affect the quality of care. Client admissions is a characteristic that reflects the volume and complexity of the client population and the demand for nursing services.
Choice C reason: Hospital readmissions is included in the outcome category. The outcome category measures the results and consequences of the nursing care provided to the clients. Hospital readmissions is a result that indicates the effectiveness and continuity of the nursing care. A high rate of hospital readmissions can suggest poor quality of care, inadequate discharge planning, or lack of follow-up care.
Choice D reason: Staffing is not included in the outcome category, but in the structure category. The structure category measures the characteristics and resources of the health care setting that affect the quality of care. Staffing is a resource that reflects the quantity and quality of the nursing staff, such as the number, education, experience, and skill mix of the nurses.
Correct Answer is B
Explanation
Choice A reason: This statement is incorrect because right documentation is not one of the five rights of delegation. Right documentation is a responsibility of the nurse and the AP, but it is not a criterion for deciding what tasks to delegate and to whom. The five rights of delegation are right task, right circumstance, right person, right direction, and right supervision.
Choice B reason: This statement is correct because right communication is one of the five rights of delegation. Right communication means that the nurse provides clear, concise, and specific instructions to the AP, and that the AP acknowledges and understands the instructions. Right communication also involves feedback, reporting, and documentation between the nurse and the AP.
Choice C reason: This statement is incorrect because right time is not one of the five rights of delegation. Right time is a factor that affects the delegation process, but it is not a criterion for deciding what tasks to delegate and to whom. The five rights of delegation are right task, right circumstance, right person, right direction, and right supervision.
Choice D reason: This statement is incorrect because right room is not one of the five rights of delegation. Right room is a factor that affects the delegation process, but it is not a criterion for deciding what tasks to delegate and to whom. The five rights of delegation are right task, right circumstance, right person, right direction, and right supervision.
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