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. Junctional tachycardia: Junctional tachycardia originates from the AV node, typically with a narrow QRS, absent or inverted P waves, and a rate of 100–180 bpm. The strip does not show these features.
B. Second-degree Type II AV block (3:1).Type II AV block (Mobitz II) shows dropped QRS complexes with constant PR intervals before conducted beats. This strip does not show missing QRS complexes in a 3:1 pattern.
C. Ventricular fibrillation. VF is characterized by a chaotic, disorganized rhythm with no discernible P waves, QRS complexes, or T waves, completely different from this organized flutter pattern.
D. Atrial flutter is characterized by regular, rapid atrial depolarizations (flutter waves) at a rate of 250–350 bpm. These waves create a "sawtooth" pattern on the ECG.The ventricular response may be regular or irregular, depending on AV conduction. This is different from atrial fibrillation (which has irregularly irregular R-R intervals and no discrete P waves).

A. Obtain a chest x-ray to verify endotracheal tube location. B. Call the respiratory therapist (RT) to verify tube placement. C. Instill normal saline into the endotracheal tube for suctioning. D. Auscultate for breath sounds bilaterally in all lung fields.

Correct Answer is D

Explanation

A. Obtain a chest x-ray to verify endotracheal tube location. A chest x-ray is the gold standard for confirming ETT placement, but it is not the first step. Immediate bedside assessment is needed to ensure the tube is correctly positioned before relying on imaging. If the tube is misplaced in the esophagus, waiting for an x-ray could delay necessary corrections.
B. Call the respiratory therapist (RT) to verify tube placement. The nurse should first perform a rapid bedside assessment before consulting the RT. While RTs assist in confirming placement, the nurse is responsible for the initial verification of breath sounds, chest rise, and end-tidal CO₂ (ETCO₂) readings. Any concerns should be addressed immediately.
C. Instill normal saline into the endotracheal tube for suctioning. Instilling saline before suctioning is not recommended, as it can promote aspiration, decrease oxygenation, and increase infection risk. The priority is confirming that the tube is properly placed before performing any interventions such as suctioning.
D. Auscultate for breath sounds bilaterally in all lung fields. The first action after ETT placement is to auscultate bilateral breath sounds to confirm proper tube positioning. If the tube is misplaced in the esophagus, breath sounds will be absent or diminished bilaterally. If placed too deep, breath sounds may be absent on one side, indicating mainstem bronchus intubation. This immediate assessment helps identify misplacement before obtaining a chest x-ray.

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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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