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.

Answer and Explanation

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.

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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.

A. Intramuscular. B. Subcutaneous. C. Oral. D. Intravenous.

Correct Answer is D

Explanation

Choice A rationale:

Intramuscular administration involves injecting medication into muscle tissue, which may result in slower and variable absorption rates. It is not the optimal route for providing fast and complete absorption of Furosemide.

Choice B rationale:

Subcutaneous administration delivers medication into the fatty tissue beneath the skin. While it can be used for some medications, it generally results in slower absorption compared to intravenous administration, and it may not be suitable for Furosemide, which requires rapid action in a severe heart failure situation.

Choice C rationale:

Oral administration involves taking medication by mouth, and the absorption process can be influenced by factors such as gastric emptying and gastrointestinal transit time. In an urgent scenario of severe heart failure, oral administration might be too slow and unpredictable.

Choice D rationale:

Intravenous administration allows for the fastest and most complete absorption of Furosemide. By directly delivering the medication into the bloodstream, it bypasses the absorption barriers of the gastrointestinal tract, leading to rapid onset of action and predictable effects, which is crucial in managing acute heart failure. This route is commonly used in critical situations where immediate therapeutic effects are needed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A Medical-Surgical nurse is caring for a client suffering from osteoarthritis. The nurse applies warm compresses to the client's joint. Which of the following phases of nursing care is the nurse demonstrating?

Correct Answer is A

Explanation

A Medical-Surgical nurse is preparing to administer Furosemide to a patient who is having severe heart failure. Which route of administration should the nurse use to provide the fastest and most complete absorption of Furosemide?

Correct Answer is D

Explanation

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