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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. "Let's talk about what you already know about immunizing your baby.": This response uses open-ended, nonjudgmental communication to explore the parents' beliefs and knowledge. It encourages dialogue, builds trust, and opens the door for education about vaccine safety and benefits.
B. "Your baby's immunizations should be up to date before they are able to travel with you by airplane.": This statement may feel coercive or irrelevant if the parents are not currently planning to travel. It does not address their current concerns or promote open discussion.
C. "You don't have to immunize your baby against diseases that are no longer common.": Diseases like measles and pertussis can still occur and spread quickly in under-immunized communities. Vaccination remains essential to maintain herd immunity and prevent outbreaks.
D. "The provider can give you a referral for your baby to see an infectious disease provider.": Referring to a specialist at this stage may come across as dismissive or escalate the situation unnecessarily. Primary care providers and nurses can often address vaccine concerns effectively through discussion and education.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B"},"D":{"answers":"A,B,C"}}
Explanation
Rationale:
- Sensation: Tingling indicates possible nerve irritation or mild neurovascular compromise. This is often seen in fractures when swelling or bone displacement compresses nerves near the injury site, especially in long bones like the radius.
- Ecchymosis: Bruising results from soft tissue bleeding and is common in all three conditions due to trauma to blood vessels. Ligament tears (sprain), bone injury (fracture), and capsule damage (dislocation) can all lead to ecchymosis.
- Pain level: Moderate pain, such as a 4/10 rating, is consistent with both sprains and fractures. Sprains stretch or tear ligaments, while fractures disrupt bone structure. Dislocations usually present with severe, sharp pain that impairs joint movement entirely.
- Edema: Swelling is a nonspecific but common response to tissue injury. It occurs with ligament strain (sprain), bone disruption (fracture), and joint trauma (dislocation), all of which lead to localized inflammation and fluid accumulation.
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