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. A client who has an open compound fracture of the humerus: This injury requires surgical intervention and has a moderate to high risk of complications. It is typically classified as yellow, indicating delayed care is acceptable but not minor.

B. A client who has multiple facial lacerations: These are superficial injuries that can be treated with simple wound care and suturing. The client is likely stable and ambulatory, fitting the criteria for a green tag, which denotes minor injuries requiring minimal care.

C. A client who has a puncture wound in the right lower lung: This suggests potential internal injury and respiratory compromise. Such a case is urgent and unstable, requiring immediate intervention, and would be tagged red for immediate treatment.

D. A client who has full-thickness burns over the lower extremities: Full-thickness burns covering a large area are life-threatening and resource-intensive to manage. Depending on the extent, this may fall under red or black, depending on survivability and available resources.

A. "Maintain the client in a supine position for 24 hours following surgery." B. "Expect the client to have a palpable distended bladder following surgery." C. "Report bleeding that saturates the client's dressing." D. "Ensure the client's urinary output is no less than 20 mL per hour."

Correct Answer is C

Explanation

Rationale:

A. "Maintain the client in a supine position for 24 hours following surgery.": Prolonged supine positioning increases the risk of pulmonary complications such as atelectasis. Early mobilization and elevating the head of the bed help promote lung expansion and reduce postoperative risks.

B. "Expect the client to have a palpable distended bladder following surgery.": A distended bladder is not expected and may indicate urinary retention, a common complication after anesthesia. The nurse should assess and address it promptly, rather than consider it normal.

C. "Report bleeding that saturates the client's dressing.": Active bleeding that saturates a postoperative dressing may indicate hemorrhage and requires immediate intervention. Reporting this finding is critical to prevent further complications like hypovolemia or shock.

D. "Ensure the client's urinary output is no less than 20 mL per hour.": Urine output should be at least 30 mL per hour in adults. A rate below this may indicate hypoperfusion or renal impairment and should prompt further assessment and intervention.

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 has been assigned to an internal disaster drill team and is triaging clients. Which of the following clients should the nurse classify with a green tag?

Correct Answer is B

Explanation

A charge nurse is teaching newly licensed nurses about postoperative procedures following abdominal surgery. Which of the following information should the charge nurse include?

Correct Answer is C

Explanation

A nurse is providing teaching to a client who has stress incontinence. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

A nurse is caring for a client who has experienced a stillbirth. Which of the following actions should the nurse take during the initial grieving process?

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 is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following actions should the nurse take? (Select all that apply.)

A nurse is caring for a client who had a laparoscopic cholecystectomy and is experiencing abdominal distention. Which of the following actions should the nurse take?

A nurse is caring for a client who has an endotracheal tube (ET) and is on mechanical ventilation. Which of the following actions should the nurse take for a ventilator alarm due to an increase in peak airway pressure? (Select all that apply.)

A nurse is teaching a client who has herpes zoster. Which of the following statements should the nurse make?

A nurse in a clinic is caring for an adolescent client who is at 24 weeks of gestation and showing signs of preeclampsia. Which of the following findings should the nurse expect?