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 D
Explanation
Choice A reason: Outside client's room is not an appropriate area to provide report to the oncoming nurse. This area may not be private or quiet enough to ensure confidentiality and accuracy of the information. The nurse may also miss important cues or changes in the client's condition or environment.
Choice B reason: Conference area is not an appropriate area to provide report to the oncoming nurse. This area may be too far from the client's room or the nursing station, which can delay the response time or the continuity of care. The nurse may also lose the opportunity to interact with the client and the family, and to verify the data with the physical assessment.
Choice C reason: Nurse's lounge is not an appropriate area to provide report to the oncoming nurse. This area may be too informal or distracting to maintain the professionalism and focus of the report. The nurse may also violate the privacy and dignity of the client and the family by discussing their personal or medical information in a public place.
Choice D reason: Client's bedside is an appropriate area to provide report to the oncoming nurse. This area allows the nurse to involve the client and the family in the report, which can enhance their satisfaction, safety, and education. The nurse can also observe the client's condition and behavior, and perform the physical assessment and the medication reconciliation with the oncoming nurse.
Correct Answer is D
Explanation
Choice A reason: This statement does not indicate an understanding of acute care, but rather a misconception and a lack of responsibility. Acute care is a level of health care that provides immediate and short-term treatment for severe or life-threatening conditions, such as asthma attacks. Acute care requires the parents to stay with their child and participate in their care plan.
Choice B reason: This statement does not indicate an understanding of acute care, but rather a denial and a delay of treatment. Acute care is not provided at home, but at a specialized facility that has the equipment and staff to handle emergencies. Waiting for the nurse to come may worsen the child's condition and increase the risk of complications.
Choice C reason: This statement does not indicate an understanding of acute care, but rather an exaggeration and a misunderstanding of the duration of treatment. Acute care is not meant to last for a long time, but only until the condition is stabilized or resolved. The length of stay at an acute care facility depends on the severity of the condition and the response to treatment, but it is usually less than a month.
Choice D reason: This statement indicates an understanding of acute care, as it reflects the main goal and intervention of acute care for asthma. Acute care for asthma involves administering medications that can quickly relieve the symptoms and prevent further inflammation of the airways. Medications may include bronchodilators, corticosteroids, oxygen, and others.
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