A client who was involved in a motor vehicle collision while riding a motorcycle without wearing a helmet, is brought the emergency department (ED) by emergency medical services (EMS). Which assessment should the nurse obtain first?

Degree of pain using a 10 point scale.

Pulse and blood pressure.

Balance and coordination.

Bilateral pupillary reaction to light.

Answer and Explanation

The Correct Answer is B

A. Degree of pain using a 10-point scale. Pain assessment is important, but it is not the priority in an emergency trauma situation. Clients involved in motor vehicle collisions (MVCs) without a helmet are at high risk for life-threatening injuries, including hemorrhage and shock. The nurse must first assess vital signs to determine hemodynamic stability.
B. Pulse and blood pressure. The primary concern in trauma patients is circulation and perfusion. Assessing pulse and blood pressure helps determine if the client is experiencing shock, hemorrhage, or traumatic brain injury (TBI)-related autonomic dysfunction. In trauma resuscitation, the ABCs (Airway, Breathing, Circulation) guide assessment priorities, making circulatory status the first concern after ensuring airway patency.
C. Balance and coordination. A neurological assessment for balance and coordination is not a priority in a critically injured trauma patient. Severe injuries, including intracranial hemorrhage, cervical spine trauma, or internal bleeding, must be ruled out before assessing fine motor function.
D. Bilateral pupillary reaction to light. Pupillary response is part of a neurological assessment and is crucial in identifying traumatic brain injury. However, vital signs must be assessed first to determine hemodynamic stability, as untreated shock or hemorrhage can lead to rapid deterioration or death.

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Correct Answer is D

Explanation

A. Hyperglycemia. While elevated blood glucose can occur in acute pancreatitis due to pancreatic inflammation impairing insulin secretion, it is not an electrolyte imbalance. The question specifically asks about electrolyte-related manifestations.
B. Hypotension. Hypotension in acute pancreatitis is often due to fluid shifts (third-spacing) and systemic inflammation, rather than a direct electrolyte imbalance. Though dehydration and electrolyte losses can contribute to hypotension, this is not the most specific sign of an electrolyte disturbance.
C. Paralytic ileus and abdominal distention. Hypokalemia can lead to paralytic ileus, but ileus and distention are also caused by peritoneal irritation, inflammation, and impaired motility due to pancreatitis itself. While potassium imbalance could contribute, this is not the most direct electrolyte-related symptom.
D. Muscle twitching and digit numbness. Hypocalcemia is a common electrolyte imbalance in acute pancreatitis, caused by fatty acid breakdown binding calcium, leading to saponification. This results in neuromuscular excitability, causing muscle twitching, paresthesia (numbness/tingling), and positive Chvostek’s or Trousseau’s signs. These symptoms are clear indicators of an electrolyte disturbance related to pancreatitis.

A. Suction subglottic area above the ETT cuff before entering the ETT. B. Use the ventilator settings to stack breaths prior to suctioning. C. Rinse suction catheters with normal saline between each suction pass. D. Suction for 30 seconds with each pass of the suction catheter.

Correct Answer is B

Explanation

A. Suction subglottic area above the ETT cuff before entering the ETT. While subglottic suctioning helps prevent ventilator-associated pneumonia (VAP) by removing pooled secretions, it does not directly improve oxygenation during deep endotracheal suctioning. The priority is to optimize oxygenation before and after suctioning.
B. Use the ventilator settings to stack breaths prior to suctioning. Pre-oxygenating the client by delivering additional breaths via the ventilator helps prevent hypoxia during suctioning. Closed suction systems momentarily interrupt airflow, which can lead to oxygen desaturation. Providing 100% FiO₂ for 30–60 seconds before suctioning helps ensure adequate oxygenation and reduces complications.
C. Rinse suction catheters with normal saline between each suction pass. Flushing the catheter keeps it clean and patent, but it does not enhance oxygenation. Normal saline instillation before suctioning is not recommended, as it can increase infection risk and worsen secretion mobilization.
D. Suction for 30 seconds with each pass of the suction catheter. Prolonged suctioning can cause severe hypoxia, bradycardia, and airway trauma. Suction passes should be limited to 10–15 seconds to minimize complications. If additional suctioning is needed, the client should be reoxygenated between passes.

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A client who was involved in a motor vehicle collision while riding a motorcycle without wearing a helmet, is brought the emergency department (ED) by emergency medical services (EMS). Which assessment should the nurse obtain first?

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Naxlex Comprehensive Predictor Exams

The nurse identifies the collaborative problem of potential electrolyte imbalance in a client with acute pancreatitis. Which assessment finding should the nurse associate with an electrolyte imbalance related to acute pancreatitis?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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