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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Keeping a body map of skin lesions is a key strategy for monitoring changes in the skin over time. This helps individuals track any new or changing lesions, which is crucial for early detection of skin cancer.
B. Reducing tanning bed use is important because tanning beds are a significant risk factor for skin cancer. However, the instruction should emphasize complete avoidance rather than just reduction, as tanning beds dramatically increase the risk of melanoma.
C. Examining your body every 2 months is not frequent enough for effective skin cancer monitoring. Monthly self-examinations are generally recommended to catch potential changes early.
D. Avoiding the sun after 3 p.m. is incorrect; the most dangerous sun exposure typically occurs between 10 a.m. and 4 p.m. The instruction should advise avoiding the sun during peak hours or wearing protective clothing and sunscreen.

A. Placing the client on a ventilator to remove carbon dioxide (CO2) B. Advising the client to use their call light to reduce the risk of falls C. Providing the client a high protein diet D. Administering antibiotics and maintaining the mean arterial pressure (MAP) at least 65 mm Hg

Correct Answer is D

Explanation

A. Placing the client on a ventilator to remove CO2 is not directly related to preventing the development of MODS. While ventilation might be necessary for respiratory support, it does not address the systemic infection and inflammation that contribute to MODS.
B. Advising the client to use their call light to reduce the risk of falls is important for general safety but does not address the critical factors involved in preventing MODS in the context of SIRS.
C. Providing a high protein diet can support overall nutrition and healing but is not the primary intervention for preventing MODS. Managing the infection and maintaining hemodynamic stability are more critical.
D. Administering antibiotics to treat the bacterial infection and maintaining a mean arterial pressure (MAP) of at least 65 mm Hg are essential interventions. Effective antibiotic therapy addresses the infection, and maintaining MAP ensures adequate organ perfusion, both of which help prevent the progression to MODS.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is D

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