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 A

Explanation

Choice A Reason: Dobutamine is a positive inotropic agent that increases the contractility of the heart and improves cardiac output. This leads to increased renal perfusion and urine output, which reduces the ﬂuid overload and edema associated with heart failure. Therefore, this choice is correct.

Choice B Reason: Dobutamine does not have a direct eﬀect on blood glucose level. It may cause hyperglycemia as a side eﬀect, but this is not an indication of its eﬀectiveness. Therefore, this choice is incorrect.

Choice C Reason: Dobutamine may cause a slight decrease in blood pressure due to vasodilation, but this is not its main therapeutic eﬀect. A significant decrease in blood pressure may indicate hypovolemia, hypotension, or shock, which are adverse eﬀects of dobutamine. Therefore, this choice is incorrect.

Choice D Reason: Dobutamine also has a positive chronotropic eﬀect, which means it increases the heart rate. However, this is not a desired outcome for a client with heart failure, as it increases the oxygen demand of the heart and may worsen the condition. Therefore, this choice is incorrect.

A. Cause of the burn B. Age of the client C. Associated medical history D. Location of the burn

Correct Answer is D

Explanation

Choice A Reason: Cause of the burn is not the nurse's priority when assessing the severity of the client's burns. The cause of the burn may indicate the type and duration of exposure, such as thermal, chemical, electrical, or radiation, which can aﬀect the depth and extent of injury. However, these factors are secondary to ensuring adequate oxygenation and ventilation.

Choice B Reason: Age of the client is not the nurse's priority when assessing the severity of the client's burns. The age of the client may inﬂuence the response to burn injury, such as healing time, infection risk, and ﬂuid requirements.

However, these factors are secondary to ensuring adequate oxygenation and ventilation.

Choice C Reason: Associated medical history is not the nurse's priority when assessing the severity of the client's burns. The associated medical history may aﬀect the outcome and prognosis of burn injury, such as pre-existing conditions, medications, or allergies. However, these factors are secondary to ensuring adequate oxygenation and ventilation.

Choice D Reason: Location of the burn is the nurse's priority when assessing the severity of the client's burns. The location of the burn can indicate the potential for life-threatening complications, such as airway obstruction, inhalation injury, or impaired circulation. The nurse should assess for signs and symptoms of respiratory distress, such as stridor, wheezes, or cyanosis, and prepare for endotracheal intubation if needed. The nurse should also monitor for signs and symptoms of compartment syndrome, such as pain, pallor, paresthesia, pulselessness, or paralysis, and report any findings to the provider. The location of the burn can also aﬀect the functional and cosmetic outcomes, such as vision loss, facial disfigurement, or joint contractures. The nurse should provide appropriate wound care, pain management, and rehabilitation as prescribed. Assessing for location of burn is essential to prevent further injury and preserve vital functions.

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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

A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is eﬀective?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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