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 A

Explanation

Choice A reason: Frequent swallowing is a key indicator of post-tonsillectomy hemorrhage, as the child may swallow blood from bleeding in the surgical site. This subtle sign requires urgent assessment to prevent airway obstruction or significant blood loss, aligning with clinical priorities, making it the correct finding.
Choice B reason: Increased drowsiness may indicate pain medication effects or general recovery but is not specific to hemorrhage. While concerning, it is less urgent than frequent swallowing, which directly suggests bleeding, making this finding less indicative of hemorrhage in this context.
Choice C reason: Elevated pain is expected post-tonsillectomy due to surgical trauma and does not specifically indicate hemorrhage. Pain may persist regardless of bleeding, so this finding is less reliable than frequent swallowing for identifying potential hemorrhage, making it incorrect.
Choice D reason: Diminished breath sounds suggest respiratory complications like atelectasis or obstruction, not hemorrhage. Bleeding would more likely present with swallowing or visible blood. This finding is unrelated to tonsillectomy hemorrhage, making it an incorrect indicator for this complication.

A. Assign all available staff to the emergency department. B. Prepare to discharge stable clients to free up beds. C. Cancel all scheduled elective surgeries immediately. D. Request additional ventilators from a nearby facility.

Correct Answer is B

Explanation

Choice A reason: Assigning all staff to the emergency department disrupts care for existing inpatients and may overwhelm ED operations. Staff allocation should follow a triage plan, balancing hospital-wide needs. This action is impractical and risks neglecting other patients, making it less effective than preparing resources.
Choice B reason: Preparing to discharge stable clients frees up beds for incoming casualties, optimizing hospital capacity during a mass casualty event. This aligns with disaster protocols, ensuring resources are available for critical patients. It supports efficient triage and care delivery, making it the correct action.
Choice C reason: Canceling all elective surgeries immediately is premature without assessing the event’s scope. Some surgeries may continue if resources allow, per disaster protocols. This action disrupts hospital operations unnecessarily and is less urgent than preparing beds for casualties, making it inappropriate.
Choice D reason: Requesting ventilators assumes specific needs without assessing the casualty event’s nature. Ventilators may not be immediately required, and resource allocation should follow triage protocols. Preparing beds is a more immediate and versatile action, making this choice less prioritized in the initial response.

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 is caring for a child who is postoperative following a tonsillectomy. Which of the following findings indicates that the child may be experiencing hemorrhage?

Correct Answer is A

Explanation

A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse is preparing a client for discharge home after an admission for bilateral pulmonary emboli. The client is prescribed warfarin in addition to regular daily medications. Which of the following actions should the nurse take?

A nurse is caring for a client who has an end-stage lung disease. The client requests not to be resuscitated if their condition worsens. Which of the following actions should the nurse take?

A nurse is caring for a client who has end-stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for their parent. Which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure?

A nurse is caring for a client who has a closed wound drainage system. Which of the following interventions should the nurse include in the plan of care?

A nurse is teaching a client who has multiple sclerosis. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who is receiving 0.45% sodium chloride. Which of the following actions should the nurse take?

A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following findings requires a referral for further care?

A community health nurse is performing a home visit for a client and is evaluating the home environment for safety. Which of the following findings would indicate to the nurse that the client has a proper understanding of safety in the home?