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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A Reason: Observing for cerebrospinal ﬂuid (CSF) leaks from the evacuation site is important, but not the first action that the nurse should take. CSF leaks can indicate a breach in the dura mater, which can increase the risk of infection and meningitis. The nurse should inspect the dressing and the nose and ears for any clear or bloody drainage, and report any findings to the provider. However, these measures are secondary to ensuring adequate oxygenation and perfusion.

Choice B Reason: Checking the oximeter is also important, but not the first action that the nurse should take. The oximeter measures the oxygen saturation of the blood, which reﬂects the adequacy of gas exchange in the lungs. The nurse should maintain the oxygen saturation above 90%, and administer supplemental oxygen as prescribed.

However, these measures are secondary to ensuring adequate oxygenation and perfusion.

Choice C Reason: Assessing for an increase in temperature is another important action, but not the first one that the nurse should take. An increase in temperature can indicate an infection, inﬂammation, or damage to the hypothalamus, which can aﬀect the thermoregulation of the body. The nurse should monitor the temperature and administer antipyretics as prescribed. However, these measures are secondary to ensuring adequate oxygenation and perfusion.

Choice D Reason: Monitoring for manifestations of increased intracranial pressure is the first action that the nurse should take. Increased intracranial pressure can result from bleeding, swelling, or ﬂuid accumulation in the brain, which can compress and damage brain tissue and blood vessels. The nurse should assess for signs and symptoms of increased intracranial pressure, such as headache, nausea, vomiting, altered level of consciousness, pupillary changes, or Cushing's triad (bradycardia, hypertension, and irregular respirations). The nurse should also intervene to prevent or reduce increased intracranial pressure, such as elevating the head of the bed, maintaining normothermia, and administering osmotic diuretics. Monitoring for manifestations of increased intracranial pressure is essential to prevent further brain injury and preserve neurological function.

A. Continuous bubbling in the water-seal chamber B. Occasional bubbling in the water-seal chamber C. Fluctuations in the ﬂuid level in the water-seal chamber D. Constant bubbling in the suction-control chamber

Correct Answer is A

Explanation

Choice A Reason: Continuous bubbling in the water-seal chamber indicates an air leak in the chest tube system, which can compromise the drainage of air and ﬂuid from the pleural space and impair lung expansion.

Choice B Reason: Occasional bubbling in the water-seal chamber is normal and expected, as it indicates that air is being removed from the pleural space.

Choice C Reason: Fluctuations in the ﬂuid level in the water-seal chamber are normal and expected, as they reﬂect changes in intrathoracic pressure during inspiration and expiration.

Choice D Reason: Constant bubbling in the suction-control chamber is normal and expected, as it indicates that suction is being applied to the chest tube system.

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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?

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