A nurse is caring for a client who has had a traumatic fall. Which of the following interventions should the nurse implement first?
Administer acetaminophen by mouth for pain control
Perform a thorough health history
Prepare for a STAT non-contrast CT scan
Insert an indwelling urinary catheter to monitor urine output
The Correct Answer is C
A. Administer acetaminophen by mouth for pain control: While pain management is important, it is not the priority intervention in this situation. Administering acetaminophen for pain control can be done after the client's condition has been assessed and any potential serious injuries, such as head trauma, have been addressed.
B. Perform a thorough health history: Obtaining a health history is essential for understanding the client's baseline health status and any pre-existing conditions that may affect their current condition. However, in the acute phase following a traumatic fall, the priority is to assess and manage any potential life-threatening injuries.
C. Prepare for a STAT non-contrast CT scan: This is the correct answer. In cases of traumatic falls, particularly when there is concern for head injury or intracranial bleeding, obtaining a non-contrast CT scan of the head is a priority. This imaging study helps identify any intracranial injuries such as hemorrhage or skull fractures, allowing for prompt intervention if necessary.
D. Insert an indwelling urinary catheter to monitor urine output: Monitoring urine output is important for assessing renal function, but it is not the priority intervention in the immediate aftermath of a traumatic fall. The focus initially should be on assessing and managing potential life-threatening injuries, particularly those related to head trauma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
A. Colchicine:
Colchicine is commonly used in the treatment of pericarditis, especially in cases of recurrent or refractory pericarditis.
It helps reduce inflammation and alleviate symptoms by inhibiting the migration of neutrophils to the inflamed pericardium.
Colchicine is often used in conjunction with nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids for the management of pericarditis.
B. Acetaminophen:
Acetaminophen is a pain reliever and fever reducer commonly used to manage mild to moderate pain associated with various conditions, including pericarditis.
While acetaminophen may provide symptomatic relief, it is not typically considered a primary treatment for pericarditis, especially in cases of severe or recurrent pericarditis.
C. Indomethacin:
Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID) that can help reduce inflammation and relieve pain associated with pericarditis.
NSAIDs are often used as first-line therapy for acute pericarditis to alleviate symptoms such as chest pain and fever.
However, caution should be exercised when using NSAIDs in certain populations, such as older adults or those with preexisting gastrointestinal or renal conditions.
D. Amiodarone:
Amiodarone is an antiarrhythmic medication used to treat various types of arrhythmias, including ventricular arrhythmias and atrial fibrillation.
While pericarditis may lead to certain arrhythmias, such as atrial fibrillation, amiodarone is not a first-line treatment for pericarditis itself.
However, it may be used in cases where pericarditis is complicated by arrhythmias or concomitant cardiac conditions.
E. Nitroglycerine:
Nitroglycerine is a vasodilator medication commonly used to treat angina and heart failure.
While pericarditis may cause chest pain similar to angina, nitroglycerine is not typically used as a primary treatment for pericarditis.
In fact, nitroglycerine may exacerbate symptoms of pericarditis by causing venodilation and increasing cardiac preload.
Correct Answer is D
Explanation
A. A client who has coronary artery disease (CAD) and Bell's palsy: Bell's palsy, a condition characterized by sudden, temporary weakness or paralysis of the facial muscles, does not directly increase the risk of complications following CABG surgery. While Bell's palsy may affect facial muscle function, it typically does not impact respiratory function or cardiovascular stability during surgery.
B. A client who has coronary artery disease (CAD) and chronic diverticulitis: Chronic diverticulitis, inflammation or infection of the diverticula in the colon, is not directly related to increased risk for complications following CABG surgery. While diverticulitis may require medical management and dietary modifications, it does not typically affect cardiovascular or respiratory function during surgery.
C. A client who has coronary artery disease (CAD) and chronic allergies: Chronic allergies, while they may cause respiratory symptoms such as nasal congestion or rhinitis, are not typically associated with increased risk for complications following CABG surgery. Allergies alone are unlikely to significantly impact cardiovascular stability or respiratory function during surgery compared to conditions such as COPD.
D. A client who has coronary artery disease (CAD) and chronic obstructive pulmonary disease (COPD): A client with CAD and COPD is at the highest risk for complications following coronary artery bypass graft (CABG) surgery. COPD is a chronic respiratory condition characterized by airflow limitation and increased airway resistance, often accompanied by emphysema and chronic bronchitis. These respiratory impairments can significantly impact the client's ability to tolerate anesthesia, mechanical ventilation, and postoperative respiratory function. COPD increases the risk of complications such as atelectasis, pneumonia, exacerbation of COPD, and respiratory failure following CABG surgery.
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