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 C
Explanation
Choice A rationale:
Providing wound irrigation might be necessary during the dressing change, but it is not the first action the nurse should take. First, the nurse should ensure they have all the necessary supplies to prevent interruptions during the procedure.
Choice B rationale:
While avoiding accidentally removing the drain is important, it is not the first action the nurse should take. Ensuring that all supplies are gathered and ready will help facilitate a smooth and organized dressing change.
Choice C rationale:
Gathering supplies is the priority in this situation. Having all the needed supplies readily available ensures that the dressing change can be carried out efficiently and without unnecessary delays.
Choice D rationale:
Providing analgesic medication as ordered by the provider is important for the patient's comfort during the procedure. However, it should not be the first action the nurse takes. First, the nurse should ensure that they have all the necessary supplies to conduct the dressing change safely.
Correct Answer is B
Explanation
Choice A rationale:
Washing hands for 5 to 10 seconds prior to administering medication is indeed an important safety measure, but it is not specifically related to changing or applying a transdermal patch. Hand hygiene is crucial to prevent the spread of infection, but it doesn't directly address the process of applying a patch.
Choice B rationale:
Applying the patch over a non-hairy area within the patient's skin is the correct answer. This is crucial because hair can interfere with the adhesion of the patch, leading to inadequate drug absorption. The rationale behind this is to ensure that the medication is effectively delivered through the skin into the bloodstream without any barriers such as hair. It's also important to choose a site that is clean, dry, and free from cuts or irritation.
Choice C rationale:
Leaving the previous medication patch in place is not recommended. It's essential to remove the old patch before applying a new one to prevent accumulation of the medication and to ensure accurate dosing. Failing to remove the previous patch could lead to an overdose or altered drug effects.
Choice D rationale:
Ensuring that the patient is lying down is not a specific safety measure for changing or applying a transdermal patch. The patient's position doesn't directly impact the effectiveness of the patch or the safety of the application process.
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