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. Decreasing the client's oral fluid intake is inappropriate in the postoperative period following a TURP, as adequate hydration is essential to prevent clot formation and maintain catheter patency. Limiting fluids could lead to increased clot formation and obstructed flow.
B. Weighing the client every evening is not a relevant intervention in the immediate postoperative period of TURP. Weight monitoring is more critical for fluid balance in chronic conditions such as heart failure or renal disease, not in the acute setting after TURP.
C. Monitoring urine output every 6 hours is insufficient for a client receiving continuous bladder irrigation. Immediate postoperative care requires more frequent monitoring to detect potential complications such as clot retention or hemorrhage.
D. Reminding the client that he might feel a constant urge to void is essential. Continuous bladder irrigation can cause bladder spasms and a persistent sensation of needing to urinate, which is common after TURP. This helps the client understand and cope with these sensations, reducing anxiety and unnecessary concern.
Correct Answer is A
Explanation
A. Cholelithiasis (gallstones) is a known risk factor for acute pancreatitis, as gallstones can block the bile duct and lead to inflammation of the pancreas.
B. Addison disease is not directly associated with an increased risk of acute pancreatitis. It primarily affects adrenal gland function.
C. Hypothyroidism does not typically influence the risk of developing acute pancreatitis. The condition primarily affects metabolism.
D. Gout is a condition related to elevated uric acid levels and is not a direct risk factor for acute pancreatitis.
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