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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Social relationship with peers: Evaluating peer relationships helps determine the client’s emotional support system, which can influence stress levels and coping during pregnancy. However, this assessment does not pose an immediate impact on the physiologic wellbeing of the mother or fetus. It becomes more relevant after ensuring that no urgent health concerns are present.
B. Plans for attending school while pregnant: Exploring educational plans is important for long-term stability and preventing adverse socioeconomic outcomes. Although valuable for overall wellbeing, it is not an immediate safety concern. Educational planning should be addressed after assessing the pregnancy for factors that directly affect maternal–fetal health.
C. Understanding of infant care: Assessing knowledge of infant care helps identify educational needs before delivery and supports better neonatal outcomes. However, this is a future-oriented consideration and does not address the adolescent’s immediate health status. It becomes appropriate once urgent physiologic needs are evaluated.
D. Current nutritional status: Adolescents already have increased nutritional requirements for their own growth, and pregnancy further elevates these demands. Poor nutrition can lead to anemia, low birth weight, preterm birth, and delayed fetal growth, making it a priority assessment. Ensuring adequate maternal nutrition directly influences fetal development and reduces preventable complications.
Correct Answer is ["A","B","C","D","F"]
Explanation
Rationale:
A. WBC count: The client’s WBC decreased from 33,000/mm³ on postpartum day 3 to 10,000/mm³ on day 5, indicating resolution of the infection and an appropriate response to antibiotic therapy. This reflects improvement in the client’s inflammatory and immune status.
B. Fundal height: The fundus has descended from 1 cm above the umbilicus to 4 cm below the umbilicus and remains firm and midline, demonstrating normal uterine involution and a return toward pre-pregnancy size, indicating recovery from postpartum changes.
C. Temperature: The client’s temperature decreased from 38.6° C on day 3 to 37.1° C on day 5, showing resolution of the febrile response associated with infection and stabilization of her overall condition.
D. Lochia: The lochia changed from moderate, dark brown, foul-smelling on day 3 to a small amount of brownish-red, odorless lochia on day 5, reflecting improvement in uterine healing and the absence of ongoing infection.
E. Hgb: The client’s hemoglobin decreased slightly from 11.1 g/dL to 10 g/dL. While slightly lower, it remains above critical levels and is not an indicator of improvement; in fact, it shows a mild drop, likely from blood loss during delivery, so it is not considered a sign of recovery.
F. Heart rate: The client’s heart rate decreased from 110/min on day 3 to 78/min on day 5, indicating resolution of tachycardia associated with infection, pain, or stress, and reflecting stabilization of cardiovascular status.
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