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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A reason: Telling the daughter not to worry dismisses her emotional concerns and does not facilitate open communication. Addressing fears about a loved one’s death requires empathy and discussion to process grief and understand hospice care, which focuses on comfort. This response is inappropriate, as it avoids addressing the daughter’s needs.
Choice B reason: Acknowledging the daughter’s concerns about her mother’s death and inviting discussion is therapeutic. It validates her emotions, encouraging open dialogue about grief, hospice care, and end-of-life expectations. This approach supports psychological coping, aligns with palliative care principles, and helps the daughter prepare for her mother’s transition, making it appropriate.
Choice C reason: Discussing the mother’s cancer and its implications helps the daughter understand the disease progression and hospice care’s role in symptom management. This fosters informed communication, addressing fears and clarifying expectations. It supports emotional preparation for end-of-life discussions, making this response appropriate for facilitating understanding and coping.
Choice D reason: Encouraging the daughter to avoid thinking about dying dismisses the reality of the situation and hinders emotional processing. Hospice care involves preparing for end-of-life, and open discussions about death are therapeutic. This response is inappropriate, as it discourages necessary conversations about the mother’s condition and prognosis.
Correct Answer is C
Explanation
Choice A reason: Applying testosterone gel to the genital region is contraindicated, as it increases irritation and absorption variability. It should be applied to clean, dry skin on the shoulders, upper arms, or abdomen to ensure safety and efficacy, making this action incorrect and unsafe.
Choice B reason: Checking testosterone levels in 1 week is premature, as steady-state levels typically require 2-4 weeks to stabilize. Monitoring too early may yield inaccurate results, leading to improper dose adjustments. This timing is not standard, making it an incorrect instruction.
Choice C reason: Advising the client to wait 1 hour before showering or swimming ensures adequate absorption of testosterone gel through the skin. Premature water exposure can wash off the gel, reducing efficacy. This aligns with manufacturer guidelines, making it the correct action.
Choice D reason: Applying testosterone gel every other day is incorrect, as daily application maintains consistent hormone levels for hypogonadism treatment. Alternate-day dosing disrupts therapeutic levels, reducing effectiveness. Daily use is standard, making this instruction inappropriate for proper administration.
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