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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A Reason: This is incorrect because preparing for mechanical ventilation is not the priority nursing intervention, as it is an invasive and potentially harmful procedure that should be reserved for clients who have severe respiratory failure and cannot maintain adequate oxygenation with noninvasive methods.

Choice B Reason: This is correct because administering oxygen via face mask is the priority nursing intervention, as it is a noninvasive and eﬀective way to improve oxygenation and reduce hypoxemia in a client who has low PaO2 and SaO2. Oxygen therapy can also decrease the workload of the heart and lungs and prevent further complications.

Choice C Reason: This is incorrect because preparing to administer a sedative is not the priority nursing intervention, as it may worsen the client's respiratory status and mask the signs and symptoms of hypoxemia. Sedatives should be used with caution and only after oxygenation has been optimized.

Choice D Reason: This is incorrect because assessing for indications of pulmonary embolism is not the priority nursing intervention, as it is a diagnostic rather than a therapeutic action. Pulmonary embolism is a possible cause of the client's condition, but it does not address the immediate problem of hypoxemia.

A. The laboratory values are within the expected reference range. B. The laboratory values are prolonged. C. The laboratory values are the same as the previous test values. D. The laboratory values are decreased.

Correct Answer is B

Explanation

Choice A Reason: This is incorrect because the laboratory values are not within the expected reference range in a client who has DIC. DIC is a condition that causes abnormal activation of the clotting cascade, leading to widespread microthrombi formation and consumption of clotting factors and platelets. This results in bleeding complications and organ dysfunction.

Choice B Reason: This is correct because the laboratory values are prolonged in a client who has DIC. PT, aPTT, and INR are tests that measure the time it takes for blood to clot. PT measures the extrinsic pathway, aPTT measures the intrinsic pathway, and INR is a standardized ratio of PT. In DIC, these tests are prolonged because of the depletion of clotting factors and platelets.

Choice C Reason: This is incorrect because the laboratory values are not the same as the previous test values in a client who has DIC. DIC is an acute and dynamic condition that can change rapidly depending on the underlying cause and treatment. The laboratory values may ﬂuctuate between normal, prolonged, or shortened depending on the balance between clotting and bleeding.

Choice D Reason: This is incorrect because the laboratory values are not decreased in a client who has DIC. Decreased laboratory values would indicate a shortened clotting time, which can occur in some cases of DIC when there is excessive clotting and thrombosis. However, this is not the typical finding in DIC, as most clients present with bleeding manifestations and prolonged clotting time.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?

Correct Answer is B

Explanation

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A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

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?

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP should the nurse make?