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":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}

Explanation

Placing the client on droplet precautions is anticipated as it is a standard practice to prevent infection, especially in immunocompromised patients like those undergoing chemotherapy.

A private room is also anticipated to reduce the risk of infection and provide a controlled environment for the patient's comfort and monitoring.

The insertion of an indwelling urinary catheter may be nonessential unless there is a specific indication, such as urinary retention or close monitoring of output in a critically ill patient, as it can increase the risk of urinary tract infections.

Checking the client's rectal temperature once daily could be contraindicated due to the risk of causing trauma or bleeding, especially considering the client's decreased platelet count, which could lead to increased bleeding risk.

Lastly, rinsing the client's mouth with 0.9% sodium chloride every 4 hours is anticipated to help manage the sore mouth, a common side effect of chemotherapy, and to maintain oral hygiene, which is crucial in preventing infections in immunocompromised patients.

A. "I developed a hematoma because an artery burst in my brain when my head hit the windshield." B. "I developed a bleed in my brain because my platelets were too high." C. "I developed a hematoma because I take a blood thinner and my head hit the windshield." D. "I developed a hematoma because my bleeding times were too low and I hit my head."

Correct Answer is C

Explanation

A. A subdural hematoma is typically caused by venous bleeding, not arterial bleeding. An arterial rupture would more likely cause an epidural hematoma, which is not the case here.
B. High platelet counts are not commonly associated with the formation of subdural hematomas. Subdural hematomas are usually due to bleeding related to anticoagulant use or trauma.
C. Taking a blood thinner like warfarin increases the risk of bleeding and hematoma formation, particularly when combined with head trauma. This statement correctly links the anticoagulant therapy and head injury as contributing factors to the subdural hematoma.
D. Low bleeding times are not a cause of hematomas. In fact, elevated bleeding times due to anticoagulant therapy would increase the risk of bleeding, not low bleeding times.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a 66-year-old client who has a new diagnosis of lung cancer. Exhibits For each potential healthcare provider's prescription at 4 weeks, click to specify if the prescription is anticipated, nonessential, or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}

Explanation

Correct Answer is C

Explanation

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