The nurse in the emergency department is caring for a client with multiple injuries following a motor vehicle crash. The client lost consciousness. has an open fracture of the left tibia, and active bleeding at the fracture site. What is the priority nursing action?
Prepare for immediate surgery to repair the open fracture
Assess for pulses in the upper and lower extremities
Place a sterile pressure dressing on the open fracture
Maintain C-spine immobilization
The Correct Answer is D
A. Prepare for immediate surgery to repair the open fracture
Surgery may be necessary, but it is not the immediate priority. The focus should be on stabilizing the client and preventing further injury.
B. Assess for pulses in the upper and lower extremities
Assessing circulation is important but is not the most immediate life-saving intervention. First, the client must be stabilized and bleeding controlled.
C. Place a sterile pressure dressing on the open fracture
While controlling bleeding is important, spinal immobilization takes precedence in trauma cases to prevent potential spinal cord injury.
D. Maintain C-spine immobilization
In a trauma patient with loss of consciousness, cervical spine injury must be assumed. Immobilization prevents further damage while other interventions are performed.
Nursing Test Bank
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Related Questions
Correct Answer is A
Explanation
A. Fluid resuscitation
Burns covering a large TBSA result in massive fluid loss due to increased capillary permeability, leading to hypovolemic shock. Fluid resuscitation with lactated Ringer’s solution using the Parkland formula is the priority to restore intravascular volume and prevent organ failure.
B. Transfer to a burn center
While this patient requires specialized burn care, the immediate priority is fluid resuscitation. After initial stabilization, transfer to a burn center can be arranged.
C. Application of sterile dressings
Wound care is important, but it is not the priority in the emergent phase. Restoring circulation and preventing shock take precedence.
D. Administer morphine 8 mg IV
Pain management is crucial, but it is secondary to restoring intravascular volume and preventing hypovolemic shock.
Correct Answer is B
Explanation
A. Mini mental status exam at admission and discharge
Useful for cognitive function but not for acute changes.
B. Performing serial Glasgow Coma Scale exams
The GCS is the best tool for tracking changes in neurologic status over time.
C. Assessing pupils for reactivity, equality, symmetry, and accommodation
Important but not comprehensive.
D. Obtaining vital signs every four hours
Useful but does not specifically assess neurologic function.
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