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 C
Explanation
Choice A reason: Gluten removal is unrelated to latex allergy, which involves immune responses to latex proteins. Gluten pertains to celiac disease, not latex-fruit syndrome. Avoiding gluten does not prevent allergic reactions to latex, making this an incorrect understanding of latex allergy management.
Choice B reason: Peanuts are linked to peanut allergies, not latex. Latex allergy involves IgE-mediated reactions to rubber proteins, not peanut proteins. While allergies may coexist, peanuts lack cross-reactivity with latex, making avoidance irrelevant for managing latex allergy symptoms or risks.
Choice C reason: Avoiding bananas is correct due to latex-fruit syndrome, where latex proteins cross-react with banana proteins like chitinases, causing allergic reactions (e.g., itching, anaphylaxis). This understanding ensures clients avoid trigger foods, reducing risk of allergic responses in latex-sensitive individuals.
Choice D reason: Dairy products are not linked to latex allergy, as they lack cross-reactive proteins. Latex reactions stem from exposure to rubber or related plant proteins, not milk. Avoidance is unnecessary, as dairy does not trigger the immunological responses associated with latex allergy.
Correct Answer is A
Explanation
Choice A reason: A BMI of 32 indicates obesity, a risk factor for surgical wound infections due to impaired tissue perfusion, reduced immune response, and prolonged healing. Excess adipose tissue increases infection likelihood, aligning with evidence-based risk factors, making this the correct finding to identify.
Choice B reason: A temperature of 36.8°C is normal and does not indicate infection risk. Fever (>38°C) post-surgery might suggest infection, but this value reflects stable physiology, making it an incorrect indicator for assessing wound infection risk in this client.
Choice C reason: A white blood cell count of 8,000/mm³ is within normal range (5,000-10,000/mm³) and does not indicate infection risk. Elevated counts suggest active infection, but this value is unremarkable, making it incorrect for identifying infection risk post-surgery.
Choice D reason: A blood glucose of 90 mg/dL is normal (74-106 mg/dL) and does not increase infection risk. Hyperglycemia (>140 mg/dL) impairs immune function, but this value indicates good control, making it incorrect for assessing wound infection risk.
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