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

Answer and Explanation

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.

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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.

A. Auscultate bowel sounds, record the findings and obtain a 12-lead ECG B. Initiate the standing prescription for v Dopamine at 16 mcg/kg/minute C. Place soft restraints on the upper extremities and sedate as necessary D. Lower the head the bed obtain a pulse ox and increase the rate of iv fluids

Correct Answer is D

Explanation

A. Auscultate bowel sounds, record the findings, and obtain a 12-lead ECG
While auscultating bowel sounds can help assess for bowel injury and an ECG is useful for monitoring cardiac function, these interventions are not the priority. The client is in shock and requires immediate intervention to restore perfusion.

B. Initiate the standing prescription for Dopamine at 16 mcg/kg/minute
Dopamine can be used to support blood pressure in shock, but fluid resuscitation is the first-line intervention in hypovolemic shock. Vasopressors like dopamine are typically added after fluid resuscitation if hypotension persists.

C. Place soft restraints on the upper extremities and sedate as necessary
The client's restlessness is likely due to hypoxia and inadequate perfusion, not agitation. Restraints and sedation would delay critical interventions and could worsen hemodynamic instability.

D. Lower the head of the bed, obtain a pulse ox, and increase the rate of IV fluids
The client is in hypovolemic shock due to suspected internal bleeding. Lowering the head of the bed improves cerebral perfusion, increasing IV fluids restores intravascular volume, and checking pulse oximetry ensures adequate oxygenation. This is the priority action to stabilize the client.

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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?

Nursing Test Bank

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