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 ["24 mL\/hr"]
Explanation
- To find the concentration of heparin in the solution, divide the amount of heparin by the volume of D5W: 25,000 units / 500 mL = 50 units/mL
- To find the infusion rate, divide the prescribed dose by the concentration: 1,200 units/hr / 50 units/mL = 24 mL/hr
- Round the answer to the nearest tenth/whole number: 24 mL/hr
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because a thrombotic stroke is caused by a clot that forms in a cerebral artery, usually due to atherosclerosis. It typically occurs gradually and does not cause a sudden, severe headache or seizure.
Choice B Reason: This is incorrect because an embolic stroke is caused by a clot that travels from another part of the body, such as the heart, to a cerebral artery. It usually occurs abruptly and does not cause vomiting or fever.
Choice C Reason: This is incorrect because a transient ischemic atack (TIA) is caused by a temporary interruption of blood flow to a part of the brain. It usually lasts less than an hour and does not cause permanent brain damage or loss of consciousness.
Choice D Reason: This is correct because a hemorrhagic stroke is caused by a rupture of a blood vessel in the brain, resulting in bleeding into the brain tissue or the subarachnoid space. It usually causes a sudden, severe headache, vomiting, seizure, and loss of consciousness. It can also cause elevated blood pressure, fever, and increased intracranial pressure.
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