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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["70"]
Explanation
- Formula: Dose = Weight (kg) × 80 units/kg
- 5600 units ÷ 80 units/kg = 70 kg
Correct Answer is D
Explanation
A. Elevate the extremity and apply an ice pack to the injured area
Elevating the extremity can help reduce swelling, but applying ice is not recommended for chemical burns as it can cause further tissue damage.
B. Contact poison control to determine the best neutralizing agent
While contacting poison control is important, it should not be the immediate first action in an emergency setting.
C. Apply a sterile dressing, wrapping the fingers separately
This is important for protecting the wound, but it is not the immediate first action needed for chemical burns.
D. Irrigate the affected area with room temperature water
Immediate irrigation with room temperature water helps to remove the chemical from the skin and dilute its effect, which is the first critical step in managing a chemical burn.
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