The nurse in the 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?
Check pupillary response to light.
Check the client's response to questions about place and time.
Assess the capillary refill.
Evaluate chest expansion.
The Correct Answer is A
Choice A rationale:
(Correct Choice) Checking pupillary response to light is a critical first step in the assessment of a client with multiple injuries following a motor vehicle crash. Pupillary changes can indicate neurological issues, increased intracranial pressure, or damage to the brainstem. Rapidly assessing pupil size, equality, and reactivity helps identify potential life-threatening conditions.
Choice B rationale:
Checking the client's response to questions about place and time is important but not the highest priority in this scenario. Neurological and physiological stability should be addressed first to ensure the client's overall well-being.
Choice C rationale:
Assessing capillary refill is valuable in assessing peripheral circulation and hydration status. However, it is not the primary concern when dealing with a client who has potentially sustained traumatic injuries, where neurological and intracranial issues need to be ruled out or addressed urgently.
Choice D rationale:
Evaluating chest expansion is relevant for assessing lung function and detecting potential injuries like rib fractures. However, given the context of a trauma client, focusing on neurological assessment takes precedence over respiratory assessment in the immediate term.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse is demonstrating the phase of nursing care known as "Implementation." During this phase, the nurse carries out the interventions and actions that were planned in the previous stages of the nursing process. In this scenario, applying warm compresses to the client's joint is a planned intervention that is being executed by the nurse.
Choice B rationale:
Planning is not the correct choice for this scenario. Planning is the phase of nursing care where the nurse sets goals, outcomes, and develops a plan of action based on the assessment data. It occurs before the implementation phase.
Choice C rationale:
Evaluation is not the correct choice for this scenario. Evaluation is the phase where the nurse assesses the outcomes of the interventions and determines whether the goals have been met. It comes after the implementation phase.
Choice D rationale:
Assessment is not the correct choice for this scenario. Assessment is the initial phase of the nursing process where the nurse collects data about the client's health status. It precedes the planning, implementation, and evaluation phases.
Correct Answer is C
Explanation
Choice A rationale:
Cleaning the wound by scrubbing the site with gauze is not an appropriate intervention for a stage 3 pressure ulcer. Scrubbing can damage the fragile tissue, increase the risk of infection, and delay wound healing. Gentle cleaning with a mild solution and avoiding trauma to the wound bed are recommended.
Choice B rationale:
Massaging reddened areas with dressing changes is contraindicated for pressure ulcers, especially stage 3 ulcers. Massaging can cause further damage to the tissues and disrupt the healing process. Dressing changes should focus on maintaining a clean and moist environment to promote healing.
Choice C rationale:
(Correct Choice) Repositioning the client at least every 2 hours is a crucial intervention to prevent further pressure ulcers and facilitate wound healing. Regular repositioning helps relieve pressure on specific areas and improves blood circulation, reducing the risk of tissue breakdown and the development of new ulcers.
Choice D rationale:
Applying a heat lamp twice a day is not recommended for stage 3 pressure ulcers. Heat can increase blood flow to the area, potentially exacerbating inflammation and delaying healing. Pressure ulcers require a clean and moist environment for optimal healing.
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