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. Slow down the oxytocin infusion: Contractions occurring every 50 seconds and lasting 2 minutes indicate severe uterine hyperstimulation, which reduces placental blood flow and contributes to late decelerations. Slowing or stopping the oxytocin helps decrease contraction intensity and frequency, improving fetal oxygenation.
B. Administer oxygen at 2 L/min per nasal cannula: Oxygen administration can support fetal oxygenation, but 2 L/min via nasal cannula delivers minimal benefit in an acute distress situation. Oxygen would be used as a supportive measure after correcting the cause of the late decelerations. The first action is reducing uterine activity by adjusting the oxytocin infusion.
C. Place the client in a lithotomy position for delivery: Lithotomy positioning is used during the second stage of labor but is inappropriate when the fetus shows signs of distress. It does not relieve uterine hyperstimulation or improve placental blood flow. Positioning that enhances perfusion, such as side-lying, would be more beneficial after reducing the oxytocin.
D. Increase the rate of IV fluid infusion of lactated Ringers: Increasing IV fluids may help improve maternal circulation, but it does not directly resolve contractions that are too frequent or prolonged. Fluids can be an adjunct intervention but should not occur before decreasing oxytocin in the presence of late decelerations.
Correct Answer is C
Explanation
Rationale:
A. "Your provider understands your illness and is acting according to your best interests.": This statement does not address the client’s concerns and may minimize their feelings. It shifts focus away from the client’s perspective rather than supporting their right to express concerns about discharge timing.
B. "I know you will be able to recover faster at home.": This statement assumes the provider’s decision is correct and discourages the client from expressing concerns. It does not advocate for the client or ensure their voice is heard in care planning.
C. "I will tell the provider about your concerns.": Communicating the client’s concerns to the provider demonstrates client advocacy. The nurse acts on behalf of the client to ensure their preferences, questions, and safety needs are considered in the discharge decision.
D. "I will contact your insurance company to see if they will pay for you to be here longer.": While insurance involvement may be relevant, the primary role of the nurse as an advocate is to convey the client’s concerns to the healthcare team rather than directly managing insurance coverage issues.
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