The nurse in a trauma unit has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?
Evaluate chest expansion.
Check pupillary response to light.
Check the client's response to questions about place and time.
Assess the capillary refill.
The Correct Answer is A
Choice A: Evaluating chest expansion is the first action that the nurse should take, because it assesses the client's respiratory status and potential for pneumothorax, which is a life-threatening condition that can result from chest trauma. The nurse should compare the movement of both sides of the chest and listen for breath sounds.
Choice B: Checking pupillary response to light is an important action, but not the first one, because it assesses the client's neurological status and potential for brain injury. The nurse should observe the size, shape, and symmetry of the pupils and their reaction to light.
Choice C: Checking the client's response to questions about place and time is another important action, but not the first one, because it assesses the client's level of consciousness and orientation. The nurse should ask the client simple questions such as their name, date, and location.
Choice D: Assessing the capillary refill is a less important action, and not the first one, because it assesses the client's peripheral circulation and tissue perfusion. The nurse should press on the client's nail beds or fingertips and observe how quickly the color returns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This choice is incorrect because it reflects the nurse's feelings rather than focusing on the client's needs. Saying "That's a hurtful thing to say" may make the client feel guilty or defensive, and it does not address the underlying cause of the client's anger or frustration.
Choice B Reason: This choice is incorrect because it sounds accusatory and confrontational rather than empathetic and supportive. Asking "Why would you say such a thing?" may make the client feel judged or criticized, and it does not explore the client's feelings or concerns.
Choice C Reason: This choice is incorrect because it dismisses the client's feelings rather than acknowledging them. Saying "Well, that's your opinion" may make the client feel ignored or invalidated, and it does not show respect or compassion for the client.
Choice D Reason: This choice is correct because it invites the client to express their feelings and concerns rather than shutting them down. Saying "Tell me more about that" may make the client feel heard and understood, and it may help to identify the source of their anger or frustration. The nurse can then use therapeutic communication skills such as active listening, reflecting, clarifying, or validating to establish rapport and trust with the client.
Correct Answer is A
Explanation
Choice A Reason: This choice is correct because allowing the drainage to drip onto a sterile gauze pad may help to identify if it is cerebrospinal fluid (CSF), which is a clear fluid that surrounds and protects the brain and spinal cord. CSF leakage from the nose (rhinorrhea) may indicate a basilar skull fracture, which is a serious injury that can cause intracranial bleeding, infection, or brain damage. The nurse should test the drainage for the presence of glucose or the halo sign, which are indicators of CSF.
Choice B Reason: This choice is incorrect because obtaining a culture of the specimen using sterile swabs may introduce bacteria into the nasal cavity and increase the risk of infection. The nurse should avoid inserting anything into the nose or mouth of a client who has a suspected basilar skull fracture.
Choice C Reason: This choice is incorrect because inserting sterile packing into the nares may increase the pressure in the cranial cavity and worsen the injury. The nurse should avoid applying pressure or occluding the nose or ears of a client who has a suspected basilar skull fracture.
Choice D Reason: This choice is incorrect because suctioning the nose gently with a bulb syringe may damage the nasal mucosa and cause bleeding. The nurse should avoid suctioning or irrigating the nose or ears of a client who has a suspected basilar skull fracture.
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