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?

Warm blood products prior to administration.

Establish a patent oral airway.

Create a sterile field for wound care.

Administer IV fluids to maintain blood pressure.

Answer and Explanation

The Correct Answer is B

Choice A reason: Warming blood products prevents hypothermia during transfusion but is not the priority in a trauma patient. Airway management takes precedence, as oxygenation is critical to survival. Administering blood products comes later in the trauma algorithm, after securing the airway and stabilizing breathing, making this action secondary.
Choice B reason: Establishing a patent oral airway is the first priority in trauma care, following the ABCs (Airway, Breathing, Circulation). A clear airway ensures oxygenation, critical for preventing hypoxia in a patient with multiple injuries. Without a patent airway, other interventions are ineffective, as oxygen delivery is essential for survival and organ function.
Choice C reason: Creating a sterile field for wound care is important to prevent infection but is not the first priority in a trauma patient. Airway and breathing take precedence, as immediate life-threatening issues like hypoxia or shock must be addressed before wound care, making this action lower in priority.
Choice D reason: Administering IV fluids to maintain blood pressure is part of the circulation phase in trauma care but follows airway and breathing stabilization. Without a patent airway, fluid administration cannot address hypoxia, a primary cause of mortality in trauma. This action is secondary to ensuring airway patency.

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

Choice A reason: Comparing the medication label to the provider’s prescription three times is a safety step during administration, not reconciliation. Reconciliation verifies the client’s home medications against new orders to prevent errors like omissions or duplications. This action occurs post-reconciliation, focusing on administration accuracy, not the initial verification of the medication list.
Choice B reason: Medication reconciliation involves comparing the client’s home medication list to admission prescriptions to ensure continuity and accuracy. This process identifies discrepancies, such as missed medications or incorrect doses, preventing adverse drug events. It requires verifying with the client or family and cross-checking provider orders, making it the cornerstone of safe transitions in care settings.
Choice C reason: Administering medications to treat a condition to the actual prescriptions is unclear and not part of reconciliation. Reconciliation focuses on verifying and documenting medications, not administering them. This option does not align with the systematic process of ensuring all medications are correctly prescribed upon admission, making it incorrect.
Choice D reason: Ensuring administration within 3 hours of the scheduled time relates to medication administration protocols, not reconciliation. Reconciliation verifies the accuracy of the medication list before administration. This step is about timing, not the verification process critical to preventing errors during care transitions, rendering it irrelevant to the task.

A. I think about whether I want this procedure. B. Signing this form indicates that I give permission for the procedure. C. Can you tell me more about the risks? D. I will talk with the doctor about my concerns.

Correct Answer is B

Explanation

Choice A reason: Thinking about wanting the procedure shows indecision, not consent understanding. Informed consent requires comprehension of the procedure, risks, and benefits, ensuring voluntary agreement. Contemplation alone is incomplete, failing to confirm the client’s grasp of the consent form’s legal purpose.
Choice B reason: Stating that signing indicates permission reflects understanding of informed consent, which documents voluntary agreement after receiving procedure details, risks, and benefits. This aligns with ethical and legal standards, confirming the client’s comprehension of the consent form’s role in authorizing surgery.
Choice C reason: Asking about risks indicates engagement but not consent understanding. It suggests a need for more information, not confirmation of the form’s purpose. While important, it does not reflect comprehension of the consent process as clearly as acknowledging the act of signing.
Choice D reason: Wanting to discuss concerns with the doctor shows the client seeks clarification, not that they understand the consent form’s purpose. It indicates an ongoing process, not confirmation of the form’s role in granting permission, unlike acknowledging the signing’s significance.

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 on a medical-surgical unit is performing medication reconciliation for a newly admitted client. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is providing education to a client who is reviewing a consent form for a surgical procedure. Which of the following statements by the client indicates an understanding of the consent?

Correct Answer is B

Explanation

A nurse is caring for a client who has an abdominal aortic aneurysm and reports a feeling of heaviness in the chest while ambulating in the hall. Which of the following actions should the nurse take first?

A nurse is reviewing the medical record of a male client who has schizophrenia and is taking clozapine. Which of the following findings should the nurse identify as a contraindication to the administration of clozapine?

A nurse on a mental health unit is planning care for a client who is being admitted immediately following a sexual assault. Which of the following interventions should the nurse include in the plan of care?

A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. Which of the following actions taken by the AP indicates proper technique for urinary catheter care?

A nurse is performing an abdominal assessment as part of a client’s comprehensive physical examination. Which of the following is the final step the nurse should perform?

A nurse is discussing strategies for cost containment with a group of nurse managers. Which of the following statements should the nurse include?

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?