A nurse witnesses a motor vehicle crash and finds a client who is not breathing. The nurse suspects the client has a cervical vertebrae fracture. Which of the following actions should the nurse take first?
Open the client's airway using the jaw-thrust maneuver to provide oxygenation
Check the client's cranial nerve function by assessing pupils equal, round, reactive to light, and accommodation (PERRLA)
Place the client in a rigid cervical collar
Evaluate the client for brain injury
The Correct Answer is A
A. The first priority in this situation is to open the client's airway using the jaw-thrust maneuver. This technique is preferred for clients with suspected spinal injuries to avoid further spinal cord damage. Ensuring the airway is open and providing oxygenation are immediate life-saving actions.
B. Checking cranial nerve function, including assessing pupils, is important for evaluating neurological status but is not the first action when the client is not breathing. Ensuring the airway is open and providing oxygenation is the priority.
C. While placing the client in a rigid cervical collar is important for stabilizing the spine and preventing further injury, it should be done after ensuring the airway is clear. The immediate concern is to address the client's non-breathing status.
D. Evaluating the client for brain injury is important for overall assessment but is secondary to addressing the immediate life threat of not breathing. Ensuring the airway is open and then stabilizing the spine is the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A leg and ankle fracture is serious but typically not life-threatening compared to issues involving airway obstruction or severe bleeding.
B. Flank pain radiating to the groin may indicate a kidney stone or other condition, but it is less urgent than airway obstruction.
C. A raised red rash on the abdomen could be a sign of a less urgent condition, such as a viral infection or allergic reaction, and does not require immediate intervention compared to respiratory distress.
D. Expiratory stridor indicates upper airway obstruction or severe respiratory distress, which is a life-threatening condition requiring immediate intervention. Stridor suggests possible airway compromise, which needs to be addressed urgently to prevent respiratory failure.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
Sodium level: The client's sodium level is significantly elevated (157 mEq/L), indicating hyponatremia. This is a critical finding that needs to be addressed promptly to prevent serious complications such as seizures and coma.
Heart rate: While the heart rate is slightly elevated, it is not as urgent a concern as the sodium level. Once the sodium level is stabilized, the nurse can address the heart rate if it remains elevated.
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