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A client in a one-car rollover presents with multiple injuries. Prioritize the interventions in the correct sequence.

1. Assess for spontaneous respirations.

2. Give supplemental oxygen per mask.

3. Insert a Foley catheter if not contraindicated.

4. Obtain a full set of vital signs.

5. Remove patient's clothing.

6. Secure/start two large-bore IVs with normal saline.

7. Use the chin lift or jaw thrust method to open the airway.

5, 4, 1, 7, 2, 6, 3

7, 1, 4, 2, 3, 5, 6

4, 1, 5, 7, 6, 3, 2

1, 7, 2, 6, 5, 4, 3

Answer and Explanation

The Correct Answer is D

Rationale:

A: Delays airway and breathing by starting with clothing removal and vital signs.

B: Places Foley insertion and clothing removal before IV access and exposure priorities.

C: Begins with vital signs and delays oxygen and airway management, which is unsafe in trauma.
D. This question follows trauma priority care using the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure).

Assess for spontaneous respirations (1)
This is the first priority. The nurse must immediately determine whether the client is breathing. Without respirations, all other interventions are secondary.
Open the airway using chin lift or jaw thrust (7)
If respirations are compromised or at risk, the airway must be opened next. In trauma, the jaw thrust is preferred to protect the cervical spine.
Give supplemental oxygen per mask (2)
Once the airway is open and breathing is assessed, oxygen is administered to prevent hypoxia, which can rapidly worsen outcomes in trauma patients.
Secure/start two large-bore IVs with normal saline (6)
After airway and breathing are addressed, attention turns to circulation. Large-bore IV access allows for rapid fluid resuscitation to treat or prevent shock.
Remove the patient’s clothing (5)
This step supports exposure, allowing the nurse to fully assess for hidden injuries, bleeding, or deformities. It occurs after life-threatening ABC issues are managed.
Obtain a full set of vital signs (4)
Vital signs are important but should be obtained after immediate threats to airway, breathing, and circulation are controlled.
Insert a Foley catheter if not contraindicated (3)
This is a lower-priority intervention used to monitor urine output and renal perfusion. It should be delayed until the client is stabilized and contraindications (e.g., pelvic trauma) are ruled out.

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Correct Answer is C

Explanation

Rationale:
A. Age of the client is an important consideration in overall prognosis and healing potential, as older adults and very young clients have higher morbidity and mortality from burns. However, age does not take priority over factors that immediately affect airway, breathing, and functional outcomes when determining burn severity.
B. Associated medical history, such as diabetes or cardiovascular disease, can influence healing and risk for complications, but it is a secondary consideration compared with the immediate threat posed by burns in critical areas.
C. Location of the burn is the priority factor when assessing burn severity. Burns involving the face and neck place the client at high risk for airway edema and obstruction, while burns to the upper extremities can significantly affect function. Burns in these critical areas are considered more severe regardless of total body surface area or cause, making location the most important priority.
D. Cause of the burn (thermal, chemical, electrical, or radiation) influences treatment decisions and potential complications, but it is not the primary factor when initially determining severity compared with burn location.

A. Insert an oral airway to prevent aspiration and to protect the airway. B. Offer the patient an emesis basin so that you can measure the amount of emesis. C. Prepare to suction the oropharynx while maintaining cervical spine immobilization. D. Send a specimen of the emesis to the laboratory for analysis of blood alcohol content.

Correct Answer is C

Explanation

Rationale:
A. Inserting an oral airway is not the most appropriate intervention in this situation. In a trauma patient with a possible cervical spine injury, placing an oral airway without strict spinal precautions could worsen spinal damage. In addition, oral airways are generally reserved for patients who are unconscious and lack a gag reflex; this patient is actively vomiting and may still have protective airway reflexes.

B. Offering an emesis basin does not address the primary concern of airway protection. In a trauma patient with suspected intoxication and possible head injury, the risk of aspiration is high, and simply measuring emesis does not prevent airway compromise.

C. Preparing to suction the oropharynx while maintaining cervical spine immobilization is the most appropriate intervention. Vomiting poses an immediate risk of airway obstruction and aspiration. Because the patient experienced a traumatic fall, cervical spine injury must be assumed until ruled out. Suctioning clears vomitus from the airway while spinal precautions protect against further injury, addressing the highest priority in emergency care.

D. Sending emesis to the laboratory for blood alcohol analysis is not a priority during the acute phase of trauma management. Airway protection and spinal stabilization take precedence over diagnostic testing.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

Correct Answer is C

Explanation

You have just admitted a patient to the ED following a fall from a first floor hotel balcony. The patient is 22 years old and smells of alcohol. The patient begins to vomit in the ED. Which of the following interventions is most appropriate?

Correct Answer is C

Explanation

The nurse is caring for a patient in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include which of the following interventions?

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The nurse is caring for a patient admitted to the burn unit with burns to 45% of the body. After 3 days, the nurse notes that the patients temperature is newly elevated at 100.2F (37.9C), and the patient exhibits new-onset agitation and confusion. What should the nurse do first?

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?

A nurse in an emergency room is caring for the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

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