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","C","D"]
Explanation
Choice A reason: Workshops are a resource that the nurse should include in the teaching. Workshops are short-term educational programs that provide practical skills, knowledge, or experience on a specific topic or area of interest. Workshops can help nurses to update their competencies, learn new techniques, or explore new trends in nursing practice. Workshops can also provide opportunities for networking, collaboration, and feedback from peers and experts.
Choice B reason: Nursing topics on social media are not a resource that the nurse should include in the teaching. Nursing topics on social media are informal and unregulated sources of information that may not be reliable, valid, or evidence based. Nursing topics on social media may also pose ethical and legal risks, such as breaching confidentiality, privacy, or professionalism. Nursing topics on social media may be useful for raising awareness, sharing opinions, or engaging in discussions, but they are not a substitute for formal education or research.
Choice C reason: Online continuing education is a resource that the nurse should include in the teaching. Online continuing education is a form of distance learning that offers courses, modules, or programs that can be accessed through the internet. Online continuing education can help nurses to enhance their knowledge, skills, and attitudes, and to meet the requirements for licensure, certification, or accreditation. Online continuing education can also provide flexibility, convenience, and affordability for nurses who have busy schedules or limited resources.
Choice D reason: Scholarly journals are a resource that the nurse should include in the teaching. Scholarly journals are academic publications that disseminate original research, reviews, or analyses on various topics or fields of study. Scholarly journals can help nurses to keep abreast of the latest evidence, innovations, and best practices in nursing science and practice. Scholarly journals can also stimulate critical thinking, inquiry, and curiosity among nurses who seek to advance their profession and improve their outcomes.
Choice E reason: Nursing blogs online are not a resource that the nurse should include in the teaching. Nursing blogs online are personal or professional websites that feature posts, articles, or stories written by nurses or nursing students. Nursing blogs online may provide insights, perspectives, or experiences on various aspects of nursing, but they may not be objective, comprehensive, or rigorous. Nursing blogs online may also contain errors, biases, or opinions that may not reflect the standards or values of the nursing profession. Nursing blogs online may be enjoyable, inspirational, or motivational, but they are not a source of formal education or research.
Correct Answer is C
Explanation
Choice A reason: This statement is incorrect because a nurse’s personal values can and do influence ethical decisions. The nurse should be aware of their own values and how they affect their judgment and actions. The nurse should also respect the values of others and avoid imposing their own values on the clients or colleagues.
Choice B reason: This statement is incorrect because value clarification is not related to maintaining clinical competency. Value clarification is a process of identifying, examining, and prioritizing one’s values. It can help the nurse to understand their own values and beliefs, as well as those of the clients and the profession.
Choice C reason: This statement is correct because it is important that the nurse is aware of the client’s values. The nurse should assess the client’s values and preferences, and incorporate them into the plan of care. The nurse should also respect the client’s right to self-determination and autonomy, and support the client in making informed decisions.
Choice D reason: This statement is incorrect because a nurse's behaviors and actions are not called values. Values are the beliefs and principles that guide one’s decisions and actions. A nurse's behaviors and actions are the expressions of their values, as well as their knowledge, skills, and attitudes.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.