A nurse is calculating the intake of a client during the past 9 hours.

The client's intake includes:

• Lactated Ringer's IV at 150 mL/hr
• cefazolin 2 g IV intermittent bolus in 100 mL of 0.9% sodium chloride
• two units of packed RBCs of 275 mL and 250 mL
• two IV bolus infusions of 250 mL of 0.9% sodium chloride
• ranitidine 50 mg IV intermittent bolus in 50 mL of dextrose 5% in water.

How many mL of intake should the nurse record?

Choice A rationale

Stabilizing the cervical spine prevents further spinal injury in case of vertebral damage, which is a priority when managing trauma patients until specialized medical care becomes available.

Choice B rationale

While controlling bleeding is essential, it is secondary to stabilizing the cervical spine since the airway and neurological protection take precedence in trauma protocols.

Choice C rationale

The head tilt chin lift method should not be used if cervical spine injury is suspected, as it may exacerbate potential damage to the vertebrae or spinal cord.

Choice D rationale

While not moving the victim is critical, stabilization of the cervical spine is the primary intervention to prevent further injury before emergency assistance arrives.

Choice A rationale

Squeezing the nurse’s hand on verbal request suggests neurological improvement and does not warrant urgent intervention, indicating preserved motor response and cognition.

Choice B rationale

Following commands with repetition/prompting shows mild cognitive delay or reduced processing but does not represent deterioration or life-threatening concern needing immediate action.

Choice C rationale

Purposeful movement to sternal rub implies intact motor response to noxious stimuli. It does not indicate significant neurologic worsening requiring urgent intervention.

Choice D rationale

Extending extremities in response to painful stimuli, known as decerebrate posturing, is a severe neurologic deficit indicating brainstem dysfunction and requires immediate nursing intervention.