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":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}
Explanation
Administer an analgesic: Essential. The client is experiencing sudden, sharp chest pain and appears anxious, which indicates the need for pain management.
Initiate a weight-based continuous heparin infusion: Non-essential. This intervention is related to anticoagulation management and is not indicated for the immediate management of a pneumothorax or pain.
Initiate supplemental oxygen: Essential. The client has a low pulse oximetry reading of 85%, indicating a need for supplemental oxygen to improve oxygenation.
Prepare client for a chest tube insertion: Essential. The chest x-ray shows a right upper lobe pneumothorax, and preparing for chest tube insertion is crucial for managing this condition.
Insert an indwelling urinary catheter: Non-essential. There is no indication from the client's current condition that an indwelling urinary catheter is required.
Correct Answer is C
Explanation
A. Measuring the circumference of the thigh can help assess for swelling but is not specific for neurovascular assessment.
B. Palpating the femoral pulse is not as relevant for assessing neurovascular status at the site of a femur fracture; instead, the focus is on more distal pulses and sensations.
C. Instructing the client to wiggle his toes assesses motor function and circulation to the distal extremities, which are crucial for neurovascular status.
D. Monitoring the calf for edema is not the primary method for assessing neurovascular status at the site of a femur fracture; it’s more relevant for assessing for deep vein thrombosis.
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