A young adult is admitted to the emergency department after a motor vehicle crash. The client has severe pain in the right chest due to impact with the steering wheel. Which is the priority client goal?

Decrease chest pain

Reduce the client's anxiety

Maintain adequate circulating volume

Maintain adequate oxygenation

Answer and Explanation

The Correct Answer is D

A. Decrease chest pain is important but not the highest priority. Managing pain can help with breathing, but oxygenation is the primary concern.

B. Reduce the client's anxiety is secondary to physiological needs. Anxiety can worsen dyspnea, but addressing oxygenation first is more critical.

C. Maintain adequate circulating volume is a priority if there is hemorrhage, but the question does not indicate bleeding. Oxygenation takes precedence in this case.

D. Maintain adequate oxygenation is the priority. Chest trauma can lead to pneumothorax, pulmonary contusion, or other complications that can impair gas exchange. Ensuring adequate oxygenation prevents hypoxia and respiratory failure, which are life-threatening.

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Correct Answer is B

Explanation

A. Mini mental status exam at admission and discharge

Useful for cognitive function but not for acute changes.

B. Performing serial Glasgow Coma Scale exams

The GCS is the best tool for tracking changes in neurologic status over time.

C. Assessing pupils for reactivity, equality, symmetry, and accommodation

Important but not comprehensive.

D. Obtaining vital signs every four hours

Useful but does not specifically assess neurologic function.

A. The correct rate is 6 mL/hr to deliver 200 units/hr with a concentration of 200 units of heparin m B. After contacting the prescriber about the event Nurse A should an anticipate an order for IV Vitamin K C. The nurses will complete an event report due to the medication error D. Nurse A will document about the event report in the patients electronic medical record. E. The patient has received a dose of heparin over the prescribed amount F. The patient has received 3200 units of heparin from 1700-1900.

Correct Answer is ["C","E","F"]

Explanation

A. The correct rate is 6 mL/hr

The correct calculation should be verified.

B. After contacting the prescriber, Nurse A should anticipate an order for IV Vitamin K

Protamine sulfate, not vitamin K, is the antidote for heparin.

C. The nurses will complete an event report due to the medication error

A medication error must be reported.

D. Nurse A will document about the event report in the patient’s EMR

Incident reports are internal documents and should not be documented in the EMR.

E. The patient has received a dose of heparin over the prescribed amount

Due to the increased concentration, the patient received more heparin than intended.

F. The patient has received 3200 units of heparin from 1700-1900.

This calculation confirms overdosing.

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A young adult is admitted to the emergency department after a motor vehicle crash. The client has severe pain in the right chest due to impact with the steering wheel. Which is the priority client goal?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an assessment on a client. How would the nurse best evaluate improvement or deterioration in the neurologic status?

Correct Answer is B

Explanation

Correct Answer is ["C","E","F"]

Explanation

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