A client in a one-car rollover presents with multiple injuries.
Prioritize the interventions in the correct sequence.
- Assess for spontaneous respirations.
- Give supplemental oxygen per mask.
- Insert a Foley catheter if not contraindicated.
- Obtain a full set of vital signs.
- Remove patient's clothing.
- Secure/start two large-bore IVs with normal saline.
- Use the chin lift or jaw thrust method to open the airway.
7, 1, 4, 2, 3, 5, 6.
4, 1, 5, 7, 6, 3, 2.
1, 7, 2, 6, 5, 4, 3.
5, 4, 1, 7, 2, 6, 3.
The Correct Answer is C
Choice A rationale
This sequence incorrectly places obtaining vital signs (step 4) before securing airway and oxygenation. In trauma management, the primary survey must follow the ABC (Airway, Breathing, Circulation) sequence. Assessing vitals and inserting a Foley catheter are part of the secondary survey or the end of the primary survey. Failing to stabilize the airway and breathing before taking a full set of vitals could lead to patient deterioration in an emergency rollover scenario.
Choice B rationale
This sequence starts with vital signs, which violates the fundamental principles of trauma resuscitation. In a rollover accident, the nurse must first address life-threatening airway and breathing issues. Moving directly to removing clothing (step 5) before ensuring the patient is breathing or has a clear airway is inappropriate. The priorities must focus on immediate physiological stabilization before moving to assessment tasks that do not directly treat hypoxia or airway obstruction in the trauma patient.
Choice C rationale
This sequence correctly follows the trauma primary survey (ABCDE).
Step 1 assesses breathing, followed by step 7 to open the airway if needed.
Step 2 provides oxygen for breathing support.
Step 6 addresses circulation by starting IVs for fluid resuscitation.
Step 5 involves exposure to check for hidden injuries.
Step 4 obtains vitals once life-threats are managed, and step 3 (Foley) is a later intervention. This represents the most scientific and systematic approach to trauma care.
Choice D rationale
Starting the intervention by removing clothing (step 5) and taking vital signs (step 4) ignores the immediate life-saving needs of airway and breathing management. A patient in a rollover accident may have a compromised airway or tension pneumothorax. Delaying airway opening (step 7) and oxygen administration (step 2) while focusing on vitals and exposure increases the risk of hypoxic brain injury and cardiac arrest, making this sequence unsafe and clinically unsound.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale
Pulmonary embolism causes an increase in pulmonary vascular resistance, which in turn increases the workload of the right ventricle. This back pressure is reflected in an elevated central venous pressure. The normal range for central venous pressure is 2 to 8 mm Hg. A reading of 12 mm Hg indicates that the right heart is struggling to pump blood forward through the lungs, causing volume to back up into the systemic venous circulation and the right atrium.
Choice B rationale
Mechanical ventilation, especially with the use of positive end-expiratory pressure, increases intrathoracic pressure. This increased pressure is transmitted to the heart and great vessels, which can artificially elevate the central venous pressure reading. Because the central venous pressure is measured relative to atmospheric pressure, the positive pressure within the chest pushes against the right atrium, resulting in a higher measured value even if the patient's actual fluid volume status has not significantly changed.
Choice C rationale
Hypovolemia, or a decrease in circulating blood volume, would typically cause a decrease in central venous pressure, not an elevation. When there is insufficient fluid in the vascular system, the pressure in the right atrium drops, often falling below the normal range of 2 to 8 mm Hg. Therefore, a reading of 12 mm Hg is inconsistent with a diagnosis of dehydration, hemorrhage, or other causes of low volume, as these would produce a much lower reading.
Choice D rationale
Diuretic therapy is intended to reduce fluid volume in the body by increasing urine output. Successful diuresis would lead to a reduction in the central venous pressure as the total intravascular volume decreases. If a patient has a central venous pressure of 12 mm Hg, it suggests they may be in a state of fluid overload or that the diuretics have not yet lowered the pressure to the normal range of 2 to 8 mm Hg.
Choice E rationale
Heart failure, specifically right-sided heart failure, leads to an inability of the ventricle to effectively eject blood. This results in an accumulation of blood in the right atrium and the systemic venous system, directly causing an elevation in central venous pressure. A reading of 12 mm Hg is a common finding in patients with congestive heart failure where the heart's pumping efficiency is compromised, leading to systemic venous congestion and potentially peripheral edema. .
Correct Answer is A
Explanation
Choice A rationale
The 42-year-old client exhibits signs of a potential tension pneumothorax or flail chest, evidenced by dyspnea and chest asymmetry. In trauma triage, airway and breathing take absolute precedence over other injuries. Chest asymmetry suggests a major mechanical disruption of ventilation that can quickly lead to respiratory arrest or obstructive shock. This client requires immediate assessment and intervention, such as chest tube insertion or needle decompression, to stabilize their breathing and ensure adequate systemic oxygenation.
Choice B rationale
Facial lacerations in a 4-year-old are distressing but usually do not represent an immediate threat to life unless the airway is obstructed by blood or edema. If the child is crying and breathing, the airway is currently patent. While pediatric patients are often prioritized due to their physiological vulnerability, the mechanical respiratory distress seen in the adult client with chest asymmetry is a more urgent clinical priority. Lacerations can be managed after the primary survey and stabilization of breathing.
Choice C rationale
Blunt abdominal trauma in a 30-year-old carries a risk for internal hemorrhage and organ rupture. This client requires close monitoring of vital signs and possibly an ultrasound or CT scan. While potentially life-threatening if the client enters hemorrhagic shock, the immediate airway and breathing compromise in the client with chest asymmetry is a higher priority. In the ABCDE triage sequence, breathing issues are addressed before circulatory issues like potential abdominal bleeding are fully managed.
Choice D rationale
A fractured arm in a 17-year-old is generally considered a non-urgent or "green tag" injury in a mass casualty or trauma triage setting, provided there is no massive external hemorrhage. Although the client is in pain and requires splinting and imaging, this musculoskeletal injury does not compromise the airway, breathing, or overall hemodynamic stability. This client can wait for treatment while more critically injured individuals with respiratory or circulatory distress are stabilized by the medical team.
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