A nurse is caring for a client who is at 32 weeks of gestation.

Exhibits

After reviewing the client’s health record, which of the following actions should the nurse take? Select all that apply

A. A client who reports left arm pain following a fall: While the client might have a fracture or soft tissue injury, it is not immediately life-threatening.

B. A client who has hypertension and reports a severe headache: A severe headache in a client with hypertension can indicate hypertensive crisis or encephalopathy, which can lead to cerebral hemorrhage, stroke, or organ damage. This client requires immediate assessment and intervention to prevent life-threatening complications.

C. A client who has heart failure and received a diuretic 30 min ago: This client should be monitored, but no acute complication is indicated at present.

D. A client who reports frequent and painful urination: These are symptoms of a urinary tract infection, which is uncomfortable but not an emergency compared to the risk of cerebral complications in hypertensive crisis.

Rationale:

A. Warm blood products prior to administration is appropriate to prevent hypothermia during transfusion, but this is not the first priority. Circulation is addressed after airway and breathing in the ABC priority framework.

B. Establishing a patent airway is the first priority following trauma, as airway obstruction can lead to immediate hypoxia and death. According to the ABCs of emergency care (Airway, Breathing, Circulation), airway management always comes before any other intervention. The nurse must ensure airway patency through positioning, suctioning, or inserting an airway device if necessary.

C. Assigning a Glasgow Coma Scale (GCS) score is essential to assess neurologic status, but this occurs after airway, breathing, and circulation are stabilized.

D. Removing the client’s clothing helps assess injuries and prevent contamination, but it is not the first step; airway management precedes exposure in trauma care protocols