The client is brought to the ER after falling off a roof and landing on his back. A T4 spinal fracture is diagnosed. The client's blood pressure is 74/40 mmHg, pulse is 55/min, and skin is pink and dry. What of the following nursing actions is a priority?
Determine if blood is present in urine
Perform a neurological assessment
Administer IV normal saline
Perform a 12-lead electrocardiogram
The Correct Answer is C
Choice A rationale: Although important to assess for potential kidney injury, addressing hypotension due to potential spinal shock takes priority.
Choice B rationale: Important for determining any neurological deficits, but addressing hypotension is the initial priority.
Choice C rationale: Hypotension indicates potential spinal shock or hemorrhagic shock, and fluid resuscitation is the immediate priority to stabilize the client's blood pressure.
Choice D rationale: While important for assessing cardiac status, addressing hypotension takes precedence to stabilize the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: Used primarily for gout and familial Mediterranean fever, not for Paget's disease.
Choice B rationale: Alendronate is a bisphosphonate commonly used to manage Paget's disease by slowing down bone breakdown and reducing the risk of complications.
Choice C rationale: Prednisone is a corticosteroid used for various inflammatory conditions but not typically prescribed for Paget's disease.
Choice D rationale: Used to lower uric acid levels and prevent gout attacks, not a primary medication for Paget's disease.
Correct Answer is A
Explanation
Choice A rationale: This is because removing a large amount of fluid from the abdominal cavity can cause a sudden decrease in intra-abdominal pressure, which can lead to hypovolemia and hypotension. The body compensates by increasing the heart rate to maintain cardiac output and perfusion.
Choice B rationale: This is not directly related to paracentesis and may indicate other conditions.
Choice C rationale: This is not directly related to paracentesis and may indicate other conditions.
Choice D rationale: This is not directly related to paracentesis and may indicate other conditions.
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