A nurse is caring for a client who is in the emergency department with multiple traumatic injuries following a motor-vehicle crash. Which of the following actions should the nurse take first?

Establish a patent oral airway.

Remove the client's clothing.

Warm blood products prior to administration.

Assign the client a score on the Glasgow Coma Scale

Answer and Explanation

The Correct Answer is A

Rationale:

A. Establish a patent oral airway: The airway is the highest priority in trauma care, following the ABCs (Airway, Breathing, Circulation). Without a patent airway, the client cannot oxygenate properly, which can quickly become life-threatening.

B. Remove the client's clothing: This helps with full-body assessment and prevention of missed injuries, but it should only be done after ensuring the client’s airway and breathing are stable.

C. Warm blood products prior to administration: While this helps prevent hypothermia during transfusion, warming blood is not the immediate priority in a trauma situation. Circulation support follows airway and breathing in priority.

D. Assign the client a score on the Glasgow Coma Scale: Neurological assessment is important but comes after airway stabilization. The GCS helps evaluate consciousness but should not delay securing the airway in an emergency.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:

A. I should clean my stoma with moisturizing soap: Moisturizing soaps can leave a residue that interferes with the adhesive of the pouching system. The stoma area should be cleaned with warm water or a mild, non-moisturizing soap to ensure the pouch adheres properly.

B. I should cut my pouch opening 1/8 inch larger than my stoma: The opening should be just slightly larger than the stoma about 1/8 inch to prevent constriction while still protecting the surrounding skin from effluent and minimizing skin irritation.

C. I should expect my stoma to be blistered: A healthy stoma should appear moist, pink or red, and smooth. Blistering is a sign of skin breakdown or irritation and indicates improper pouch fitting or leakage, which requires intervention.

D. I should change my stoma pouch 30 minutes after heals: There isn't a specific 30-minute post-meal rule. The most important guideline for changing a pouch is when it's about one-third to one-half full, or if there is leakage or discomfort.

A. "Tell me how you are feeling about your mom dying." B. "You sound like you have questions about your mom dying. Let's talk about it." C. "Let's talk about your mom's cancer and how things will progress from here." D. "Tell her not to worry. She still has plenty of time left." E. "Hospice will take good care of your mom, so I wouldn't worry about that."

Correct Answer is ["A","B","C"]

Explanation

Rationale:

A. "Tell me how you are feeling about your mom dying.": This encourages the daughter to express her emotions, which is an important first step in processing grief and finding the right words to support her mother. It shows empathy and opens a therapeutic conversation.

B. "You sound like you have questions about your mom dying. Let's talk about it.": This response invites the daughter to engage in a meaningful discussion about her concerns. It provides emotional support and creates a safe space for her to ask questions and gain clarity.

C. "Let's talk about your mom's cancer and how things will progress from here.": Educating the daughter about the disease process and what to expect during hospice care can reduce anxiety and help her feel more prepared to have honest conversations with her mother.

D. "Tell her not to worry. She still has plenty of time left.": This response offers false reassurance and avoids the reality of the situation. It can prevent the daughter from addressing important emotional or end-of-life discussions with her mother.

E. "Hospice will take good care of your mom, so I wouldn't worry about that.": Although hospice provides excellent care, this response shifts the focus away from the daughter’s emotional needs and discourages open communication about death and dying.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who is in the emergency department with multiple traumatic injuries following a motor-vehicle crash. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has an ileostomy about the care of their stoma site. Which of the following statements made by the client indicates the teaching was effective?

Correct Answer is B

Explanation

A nurse is caring for a client who has cancer and is being transferred to hospice care. The client's daughter tells the nurse, "I'm not sure what to say to my mom if she asks me about dying." Which of the following responses by the nurse is appropriate? (Select all that apply.)

Correct Answer is ["A","B","C"]

Explanation

A nurse is caring for a client who is seeking information about end-of-life decisions. According to the Patient Self-Determination Act, which of the following applies to medical decisions that can be made within organizations that receive Medicare and Medicaid reimbursements?

A charge nurse in a newborn nursery is providing information to a group of nurses about risk factors for hypoglycemia. Which of the following risk factors should the charge nurse include? (Select all that apply.)

A nurse in an emergency department is receiving report for four clients. Which of the following clients should the nurse see first?

A nurse is providing education to a client during a prenatal visit. Which of the following medications should the nurse include as contraindicated during pregnancy?

A nurse is providing education to a client who is scheduled for a left knee arthroplasty. Which of the following statements regarding informed consent indicates client understanding of the teaching?

The nurse is continuing to care for the child. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The nurse should anticipate a prescription for dropdown and dropdown.

A nurse is caring for a client who has an end-stage lung disease. The client requests not to be resuscitated if their condition worsens. Which of the following actions should the nurse take?