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 A
Explanation
Rationale:
A. Sit at or below the client's eye level during feedings: Positioning the nurse at or slightly below the client’s eye level promotes effective communication and allows close observation of swallowing. It helps the nurse monitor for signs of aspiration, coughing, or choking, which is critical in clients with dysphagia to ensure safety during meals.
B. Instruct the client to lift her chin when swallowing: Clients with dysphagia should be taught to tuck the chin slightly toward the chest, not lift it, to protect the airway and facilitate safer swallowing. Lifting the chin increases the risk of aspiration and airway compromise.
C. Talk with the client during her feeding: Talking while swallowing increases the risk of aspiration because it distracts the client and can disrupt coordinated swallowing. Silence and focused attention are recommended during feeding to ensure safe intake of food and liquids.
D. Discourage the client from coughing during feedings: Coughing is a protective reflex that clears the airway if food or liquid enters the trachea. Discouraging it could increase the risk of aspiration and choking, making it unsafe to suppress this natural defense mechanism.
Correct Answer is A
Explanation
Rationale:
A. Confusion: Confusion is an early neurological manifestation of hypoglycemia caused by insufficient glucose supply to the brain. Clients may also experience irritability, shakiness, or difficulty concentrating, which are key indicators to assess for after insulin administration.
B. Acetone breath: Acetone or fruity breath odor is associated with diabetic ketoacidosis (DKA), a hyperglycemic emergency, not hypoglycemia. This occurs due to ketone buildup when insulin is deficient, which is opposite of low blood glucose.
C. Polydipsia: Excessive thirst is a symptom of hyperglycemia, not hypoglycemia. It occurs when elevated glucose levels cause osmotic diuresis, leading to dehydration and thirst, and is not expected shortly after insulin lispro administration.
D. Hot, dry skin: Hot, dry skin is typically associated with hyperglycemia or fever. In hypoglycemia, the client often exhibits cool, clammy skin due to sympathetic nervous system activation and sweating, making this finding inconsistent with low blood glucose.
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