A nurse finds a client who is not breathing. The nurse does not suspect any cervical vertebrae fractures. Which of the following actions should the nurse take first?

Evaluate the client for other injuries.

Open the client's airway using the head tilt-chin lift.

Open the client's airway using the jaw-thrust maneuver.

Place the client in a rigid cervical collar.

Answer and Explanation

The Correct Answer is B

A. Evaluating for other injuries is important but not the immediate priority.
B. If no cervical spine injury is suspected, the head tilt-chin lift is the recommended method to open the airway first in an apneic client.
C. The jaw-thrust maneuver is used when cervical spine injury is suspected to avoid neck movement.
D. Applying a rigid cervical collar is not necessary if no cervical injury is suspected.

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Correct Answer is C

Explanation

A. Restricting fluid intake is inappropriate. Clients are typically encouraged to increase fluids to flush out contrast dye.
B. Ambulating the client 1 hr after the procedure is unsafe. The client should remain flat with the leg extended to prevent bleeding from the femoral site.
C. Perform neurovascular checks with vital signs. This helps assess for complications such as bleeding, hematoma, or impaired perfusion in the affected limb after femoral artery access.
D. Performing range-of-motion exercises is not advised immediately after the procedure as it could disrupt the catheterization site and increase bleeding risk.

A. A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site B. A client who has a simple fracture of the femur, multiple scratches on both legs, and is crying hysterically C. A female who is pregnant at 20 weeks of gestation, has multiple cuts and abrasions, and is walking around D. A client who has severe head injuries, respiratory rate 6/min, and is unresponsive

Correct Answer is A

Explanation

A. An open chest wound with a hissing sound indicates a sucking chest wound causing a potential tension pneumothorax, which is life-threatening but potentially reversible with immediate intervention—this client requires immediate priority.
B. Simple fractures and superficial injuries are less urgent and can wait.
C. A stable pregnant client who is ambulatory with minor injuries is lower priority.
D. Severe head injury with a very low respiratory rate and unresponsiveness indicates a poor prognosis; in mass casualty triage, this client may be categorized as expectant (lowest priority for immediate intervention).

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A nurse finds a client who is not breathing. The nurse does not suspect any cervical vertebrae fractures. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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