A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?
Preventing musculoskeletal disability
Airway protection
Stabilizing cardiac arrhythmias
Decreasing intracranial pressure
The Correct Answer is B
Choice A Reason: Preventing musculoskeletal disability is important, but not the priority focus of care. The nurse should first assess and manage the client's life-threatening injuries, such as airway obstruction, bleeding, shock, or brain injury.
Choice B Reason: Airway protection is the priority focus of care for a client with multiple system trauma. The nurse should ensure that the client has a patent airway and adequate ventilation, as any compromise in these areas can quickly lead to hypoxia, respiratory failure, and death.
Choice C Reason: Stabilizing cardiac arrhythmias is also important, but not the priority focus of care. The nurse should monitor the client's cardiac rhythm and treat any arrhythmias that may occur, but only after securing the airway and breathing.
Choice D Reason: Decreasing intracranial pressure is another important goal, but not the priority focus of care. The nurse should assess the client's neurological status and intervene to prevent or reduce increased intracranial pressure, such as elevating the head of the bed, maintaining normothermia, and administering osmotic diuretics. However, these measures are secondary to ensuring adequate oxygenation and perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because magnesium 2.5 mEq/L is a normal value and does not indicate an increased risk of AKI. Magnesium is an electrolyte that plays a role in muscle and nerve function, blood pressure regulation, and energy production. The normal range for magnesium is 1.5 to 2.5 mEq/L.
Choice B Reason: This is incorrect because serum osmolality 290 mOsm/kg H2O is a normal value and does not indicate an increased risk of AKI. Serum osmolality is a measure of the concentration of solutes in the blood, such as sodium, glucose, and urea. The normal range for serum osmolality is 275 to 295 mOsm/kg H2O.
Choice C Reason: This is incorrect because blood urea nitrogen (BUN) 20 mg/dL is a normal value and does not indicate an increased risk of AKI. BUN is a measure of the amount of urea, a waste product of protein metabolism, in the blood. The normal range for BUN is 7 to 20 mg/dL.
Choice D Reason: This is correct because serum creatinine 1.8 mg/dL is an elevated value and indicates an increased risk of AKI. Creatinine is a waste product of muscle metabolism that is filtered by the kidneys. The normal range for serum creatinine is 0.6 to 1.2 mg/dL for women and 0.7 to 1.3 mg/dL for men. An increase in serum creatinine indicates a decrease in kidney function and glomerular filtration rate (GFR).
Correct Answer is C
Explanation
Choice A Reason: This choice is incorrect because laboratory testing of serum potassium upon admission is an appropriate prescription for a client who has acute heart failure following MI. Serum potassium is an electrolyte that affects the cardiac function and rhythm. A normal serum potassium range is 3.5 to 5 mEq/L, and an abnormal level can indicate hypokalemia or hyperkalemia, which can cause arrhythmias, muscle weakness, or paralysis. Therefore, monitoring serum potassium is important to detect and correct any electrolyte imbalance and prevent complications.
Choice B Reason: This choice is incorrect because bumetanide 1 mg IV bolus every 12 hr is an appropriate prescription for a client who has acute heart failure following MI. Bumetanide is a loop diuretic that helps to reduce fluid retention and edema by increasing the urine output and sodium excretion. It may be used for clients who have heart failure, hypertension, or renal impairment, but it can cause hypokalemia, hypotension, or dehydration.
Therefore, administering bumetanide as prescribed can help to improve the cardiac output and reduce the preload and afterload.
Choice C Reason: This choice is correct because 0.9% normal saline IV at 50 mL/hr continuous is an inappropriate prescription for a client who has acute heart failure following MI. 0.9% normal saline is an isotonic solution that contains the same concentration of solutes as blood plasma. It may be used for clients who have fluid loss, dehydration, or shock, but it can worsen fluid overload and pulmonary edema in clients who have acute heart failure. Therefore, clarifying this prescription with the provider is necessary to prevent further deterioration of the client's condition.
Choice D Reason: This choice is incorrect because morphine sulfate 2 mg IV bolus every 2 hr PRN pain is an appropriate prescription for a client who has acute heart failure following MI. Morphine sulfate is an opioid analgesic that helps to relieve pain and anxiety by binding to the opioid receptors in the brain and spinal cord. It may be used for clients who have moderate to severe pain, dyspnea, or chest discomfort, but it can cause respiratory depression, hypotension, or nausea. Therefore, administering morphine sulfate as prescribed can help to reduce the oxygen demand and improve the cardiac function.
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