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.

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Correct Answer is C

Explanation

Choice A reason: Checking patency every 8 hours is inadequate for closed wound drainage systems, which require more frequent monitoring (e.g., every 4 hours) to detect blockages. Delayed checks risk fluid buildup, increasing infection or seroma risk, critical in postoperative wound management.
Choice B reason: Emptying the drainage system every 24 hours may be insufficient, as frequency depends on volume. Systems like Jackson-Pratt drains need emptying when half-full to maintain suction, preventing complications like infection, requiring flexible, volume-based schedules rather than fixed intervals.
Choice C reason: Securing the drainage system to the gown prevents dislodgement, maintaining suction and reducing infection risk. It supports mobility while stabilizing the system, preventing wound tension. This is critical for effective drainage and healing in postoperative clients with closed systems.
Choice D reason: Replacing the drainage system every 3 days is unnecessary unless infection or malfunction occurs. Routine replacement risks introducing pathogens or disrupting healing. Systems remain until drainage decreases, guided by clinical assessment, not a fixed schedule, to ensure safety.

A. Maternal fever B. Chorioamnionitis C. Maternal hypoglycemia D. Fetal anemia

Correct Answer is C

Explanation

A. Maternal fever Maternal fever typically causes fetal tachycardia (elevated baseline >160/min), not bradycardia. Fever increases maternal metabolic rate and fetal heart rate.
B. Chorioamnionitis This intrauterine infection also leads to fetal tachycardia, due to inflammatory stress and maternal fever. It is not a cause of bradycardia.
C. Maternal hypoglycemia ✅ Low maternal glucose levels can reduce fetal energy supply and oxygenation, leading to fetal bradycardia (baseline <110/min). This is a recognized cause of sustained bradycardia.
D. Fetal anemia Fetal anemia usually results in tachycardia as the fetus compensates for reduced oxygen‑carrying capacity by increasing heart rate. It does not cause bradycardia.

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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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Correct Answer is C

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Correct Answer is C

Explanation

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