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 ["A","C","E"]

Explanation

Rationale:

A. Keep objects in the client's room in the same place: Maintaining a consistent environment helps clients with vision loss navigate safely and confidently. Sudden changes in object placement can increase the risk of disorientation and injury.

B. Ensure there is high-wattage lighting in the client's room: While good lighting benefits clients with partial vision, high-wattage lighting can cause glare or discomfort. The focus should be on well-distributed, non-glare lighting suited to individual needs rather than universally high intensity.

C. Touch the client gently to announce presence: Gently touching a visually impaired client before speaking helps avoid startling them and fosters trust. It is a respectful way to make presence known when visual cues are unavailable.

D. Approach the client from the side: Approaching from the front is preferable so the client can better perceive the nurse's presence through remaining visual fields or auditory cues. Side approaches may lead to disorientation or surprise.

E. Allow extra time for the client to perform tasks: Clients with vision loss may require additional time to complete self-care or communication tasks. Rushing them can increase stress and compromise safety, so patience supports their independence.

A. Administer magnesium sulfate to the client. B. Administer betamethasone to the client. C. Monitor the client's temperature every 2 hr. D. Monitor fetal heart rate every 4 hr.

Correct Answer is C

Explanation

Rationale:

A. Administer magnesium sulfate to the client: Magnesium sulfate is typically used for neuroprotection before 32 weeks or to manage preeclampsia; it is not indicated for rupture of membranes at 36 weeks unless there are other risk factors.

B. Administer betamethasone to the client: Betamethasone is used to enhance fetal lung maturity, most beneficial before 34 weeks. At 36 weeks, the lungs are usually mature enough that corticosteroids are not routinely indicated.

C. Monitor the client's temperature every 2 hr: This helps detect early signs of chorioamnionitis, a serious infection risk after membrane rupture, especially with prolonged rupture.

D. Monitor fetal heart rate every 4 hr: Fetal heart monitoring should be more frequent in the presence of membrane rupture to promptly identify signs of distress or infection, not every 4 hours.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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