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 B
Explanation
Choice A Reason: This is incorrect because monitoring the client's electrolyte levels is not the highest priority, as it does not address the immediate risk of airway obstruction or aspiration.
Choice B Reason: This is correct because suctioning saliva from the client's mouth is the highest priority, as it prevents airway obstruction and aspiration, which can lead to respiratory distress and infection.
Choice C Reason: This is incorrect because recording the client's intake and output is not the highest priority, as it does not address the immediate risk of airway obstruction or aspiration.
Choice D Reason: This is incorrect because performing passive range of motion on each extremity is not the highest priority, as it does not address the immediate risk of airway obstruction or aspiration.
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because right ventricular failure would cause an increase in right atrial pressure and right ventricular end-diastolic pressure, but not in PAWP, which reflects left atrial pressure and left ventricular end- diastolic pressure.
Choice B Reason: This is incorrect because fluid volume deficit would cause a decrease in PAWP, as there would be less blood volume in the pulmonary circulation.
Choice C Reason: This is correct because mitral regurgitation would cause an increase in PAWP, as the blood would back up into the left atrium and pulmonary veins due to the incompetent mitral valve.
Choice D Reason: This is incorrect because afterload reduction would cause a decrease in PAWP, as there would be less resistance to the left ventricular ejection and less blood volume in the pulmonary circulation.
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