A nurse is caring for a client who was involved in a motor-vehicle crash.
A nurse is providing care for a client who was involved in a motor-vehicle crash. Complete the following sentence.by using the list of options.
The nurse should first address the client's
The Correct Answer is {"dropdown-group-1":"D"}
1. Level of Consciousness:
2. Oxygen Saturation:
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
- Obtain intravenous access: Anticipated: Essential for administering medications, fluids, and potential emergency treatments.
- Thoracentesis: Non-essential: Typically used for pleural effusions, not primary treatment for pneumothorax; chest tube insertion is the main treatment.
- Pulmonary Function Tests (PFTs): Non-essential: Useful for diagnosing chronic respiratory conditions but not a primary intervention for pneumothorax.
- Prepare for insertion of a chest tube: Anticipated: A chest tube is often necessary to re-expand the lung and treat a significant pneumothorax.
- Obtain ABGs: Anticipated: Important for assessing the client’s oxygenation and acid-base balance due to respiratory distress.
- Computed tomography (CT) of the chest: Anticipated: CT can be used to diagnose the extent of the pneumothorax and guide treatment.
Correct Answer is []
Explanation
Condition:
A. Transfusion-associated circulatory overload (TACO)
Rationale: The client’s symptoms—dyspnea, restlessness, crackles in the lungs, jugular vein distension, and elevated blood pressure—are consistent with TACO, a condition resulting from excessive fluid volume during a blood transfusion.
Actions to Take:
C. Administer furosemide
Rationale: Furosemide is a diuretic that helps reduce fluid overload, which is a key issue in TACO.
B. Administer diphenhydramine
Rationale: Although not the primary treatment for TACO, diphenhydramine can help manage symptoms if there is a mild allergic reaction contributing to the situation.
Parameters to Monitor:
A. Intake and output
Rationale: Monitoring intake and output helps assess fluid balance and effectiveness of treatment for TACO.
D. Weight
Rationale: Weight monitoring helps assess fluid overload and effectiveness of diuretic therapy
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