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. Provide 60 mL (2 oz) of fluid intake every 5 min.: Following gastric bypass surgery, the stomach pouch is very small and cannot tolerate large or frequent volumes. Giving 60 mL every 5 minutes places the client at high risk for nausea, vomiting, dumping syndrome, and anastomotic complications. Fluid intake must be introduced slowly in small sips.

B. Ambulate the client 48 hr after the procedure.: Early ambulation is essential to prevent postoperative complications such as atelectasis, venous thromboembolism, and delayed return of bowel function. Waiting 48 hours is too long; clients should begin ambulating on the day of surgery or within the first 24 hours to promote circulation.

C. Provide a soft diet on the first postoperative day.: After gastric bypass surgery, the digestive system needs time to heal and cannot tolerate solid or semi-solid foods. Clients begin with clear liquids and progress gradually to pureed, soft, and then solid diets over several weeks.

D. Measure and compare abdominal girth daily.: Monitoring abdominal girth helps detect postoperative complications such as internal bleeding, leaks, or ileus, which may present with distention or increased abdominal size. Regular measurement provides early recognition of changes that require prompt intervention.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

Rationale for Correct Choices

• opioid intoxication: The client is drowsy, difficult to arouse, and has a respiratory rate of 10/min, all of which are hallmark findings of opioid intoxication. The presence of a needle in the antecubital space and the need for naloxone also strongly support opioid involvement. The prior history also documents opioid misuse and prior treatment with buprenorphine/naloxone, further increasing the likelihood of opioid intoxication in this episode.

• pupil characteristics: Miotic (pinpoint) pupils are a classic indicator of opioid intoxication and help differentiate it from alcohol intoxication, which typically presents with normal or enlarged pupils. The pupil response directly supports the diagnosis when paired with respiratory depression and altered level of consciousness.

Rationale for Incorrect Choices

• Alcohol withdrawal: Alcohol withdrawal presents with agitation, tremors, diaphoresis, tachycardia, hypertension, and occasionally hallucinations. This client is drowsy with decreased respiratory rate and constricted pupils, which are inconsistent with alcohol withdrawal, making this diagnosis unlikely.

• Alcohol intoxication: Alcohol intoxication often presents with slurred speech, ataxia, and altered mental status, but pupils are usually normal in size and not constricted. There is also no evidence of significant alcohol consumption reported, making alcohol intoxication less likely in this scenario.

• Opioid withdrawal: Opioid withdrawal is characterized by mydriasis (dilated pupils), diaphoresis, piloerection, tachycardia, nausea, vomiting, and agitation. The client’s current presentation of drowsiness, miotic pupils, and respiratory depression is opposite of withdrawal symptoms, ruling out opioid withdrawal.

• Amount of alcohol consumed: The client reportedly had only one beer, which is insufficient to cause coma-level depression. Alcohol intoxication severe enough to cause unresponsiveness with respiratory depression would require significantly higher intake.

• Breath sounds: Clear breath sounds do not help distinguish the cause of the altered mental status. Breath sounds are more useful for identifying respiratory complications, not for differentiating intoxication types.

• Current temperature: A normal temperature does not help identify opioid intoxication versus withdrawal. Temperature fluctuations are more common in severe withdrawal states and are not diagnostic enough to determine the underlying cause in this scenario.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

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