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.

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Correct Answer is B

Explanation

Rationale:

A. Insert the catheter into the foot: While the scalp and foot veins may be used in infants, foot veins are less preferred in mobile infants due to the risk of dislodgement. Site selection should prioritize accessible and secure veins, often in the hand or scalp.

B. Obtain a 24-gauge catheter: A 24-gauge catheter is the appropriate size for infants due to their small and delicate veins. It minimizes trauma during insertion and allows for adequate flow while reducing the risk of vein damage.

C. Use gauze to cover the IV insertion site: Transparent dressings, not gauze, are preferred for covering IV sites in infants. They allow for continuous visualization of the site to detect signs of infiltration or infection promptly.

D. Monitor the IV site every 8 hours: IV sites in infants should be monitored much more frequently due to their higher risk of infiltration, dislodgement, or phlebitis. Hourly monitoring is standard practice, especially in high-acuity or pediatric settings.

A. Compare a list of common medications to treat a condition to the actual prescriptions. B. Compare the prescription to the allergy history of the client. C. Compare the medication label to the provider's prescription on three occasions before administration. D. Compare the client's list of home medications to the admission prescriptions written for the client.

Correct Answer is D

Explanation

Rationale:

A. Compare a list of common medications to treat a condition to the actual prescriptions: This approach does not meet the definition of medication reconciliation, which focuses on comparing the client’s actual prior medications to new orders to prevent errors.

B. Compare the prescription to the allergy history of the client: While this is an important safety check, it is not the primary purpose of medication reconciliation. Allergy review is a separate step done for every prescribed medication, not specifically during reconciliation.

C. Compare the medication label to the provider's prescription on three occasions before administration: This is part of the "three checks" of medication administration to ensure accuracy and safety, but it is unrelated to the reconciliation process that occurs during admission, transfer, or discharge.

D. Compare the client's list of home medications to the admission prescriptions written for the client: This is the central process in medication reconciliation. It ensures continuity of care, prevents omissions, duplications, or interactions, and identifies changes that need clarification.

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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?

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