A nurse is caring for a client who has sustained a severe head trauma and has significant bleeding from the nose. Which of the following actions should the nurse take first?

Establish a patent airway

Prepare for a CT scan

Insert a peripheral IV line

Apply direct pressure to the nose.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Establish a patent airway: Severe head trauma with active nasal bleeding raises concern for airway obstruction from blood pooling, impaired consciousness, or loss of protective reflexes. Ensuring a patent airway prevents hypoxia, which can rapidly worsen neurologic injury. Early airway control is the priority because compromised breathing poses an immediate threat to life

B. Prepare for a CT scan: A CT scan is essential for diagnosing intracranial injuries, fractures, and sources of bleeding, but the client must first have a stable airway and adequate oxygenation. Imaging cannot safely proceed until airway patency is confirmed, since deterioration during transport is a major risk.

C. Insert a peripheral IV line: IV access is necessary for fluid resuscitation and medication administration, but it is not the most urgent action when airway compromise is suspected. The risk of hypoxia outweighs the risk of delayed IV access, and airway management must occur before secondary stabilization steps. Once the airway is secured, IV access can be safely done.

D. Apply direct pressure to the nose: Direct pressure is generally used to control epistaxis, but in severe head trauma, nasal bleeding may indicate a basilar skull fracture, and pressure could worsen underlying injury or dislodge clots. Additionally, controlling bleeding is secondary to securing the airway, as blood flow can interfere with breathing.

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Correct Answer is D

Explanation

Rationale:

A. Ventrogluteal: The ventrogluteal site is preferred for intramuscular injections because it provides a large muscle mass with minimal risk of injury to nerves or blood vessels. It is not appropriate for subcutaneous injections, which require sites with adequate subcutaneous tissue rather than deep muscle.

B. Vastus lateralis: The vastus lateralis is commonly used for intramuscular injections, especially in infants and young children. For adults, it is not a typical site for subcutaneous injections due to the thicker muscle and risk of intramuscular delivery.

C. Forearm: The forearm is generally reserved for intradermal injections, such as tuberculin testing. Its limited subcutaneous tissue makes it unsuitable for subcutaneous injections intended to be absorbed slowly.

D. Upper thigh: The anterior or lateral aspect of the upper thigh provides an adequate layer of subcutaneous tissue, making it a safe and effective site for subcutaneous injections. It allows for slower absorption of medication and is easily accessible for the nurse.

A. Dietary intake B. Sore throat C. Heart rate D. Blood pressure

Correct Answer is B

Explanation

Rationale:

A. Dietary intake: The client ate 75% of breakfast, which indicates adequate oral intake. While monitoring nutrition is important in schizophrenia, this finding does not pose an immediate safety concern or require urgent reporting.

B. Sore throat: A sore throat in a client taking clozapine is significant because clozapine can cause agranulocytosis, a potentially life-threatening reduction in white blood cells. Any signs of infection, such as sore throat or fever, must be reported immediately to prevent serious complications.

C. Heart rate: A heart rate of 98/min is slightly elevated but within acceptable limits for many adults. This finding alone does not indicate an urgent issue requiring immediate provider notification.

D. Blood pressure: A blood pressure of 102/56 mm Hg is slightly low but may be within the client’s normal range, particularly if the client experiences dizziness when changing positions. While it should be monitored, it does not require urgent reporting unless symptoms worsen.

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A nurse is caring for a client who has sustained a severe head trauma and has significant bleeding from the nose. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a subcutaneous injection to a client. Which of the following sites should the nurse choose?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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