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 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.
Correct Answer is C
Explanation
A. Desmopressin acetate is used to treat diabetes insipidus, not SIADH. In SIADH, there is excessive antidiuretic hormone causing fluid retention and dilutional hyponatremia, so this medication would not be appropriate.
B. Maintaining an IV infusion of 0.45% sodium chloride is not appropriate for SIADH, as this solution can further dilute sodium levels. Treatment usually involves hypertonic saline or fluid restriction.
C. Restricting fluid intake is a key management strategy for SIADH to address the fluid overload and help correct the low sodium levels. This action directly targets the root cause of the hyponatremia by reducing fluid intake.
D. Providing a diet with 2 g of sodium per day may not be sufficient or appropriate for treating SIADH-related hyponatremia. Fluid restriction is more critical in managing this condition.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.