A nurse in an emergency department is assisting with the care of a client who is unconscious and has trauma to multiple systems following a motor vehicle crash. Which of the following actions should the nurse take first?
Airway protection
Stabilizing cardiac arrhythmias
Preventing musculoskeletal disability
Decreasing intracranial pressure
The Correct Answer is A
Choice A reason: This action is correct because airway protection is the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's airway patency, breathing, and oxygenation, and intervene as needed to secure and maintain the airway. The nurse should also monitor the client for signs of aspiration, bleeding, or obstruction, and suction the airway as needed.
Choice B reason: This action is incorrect because stabilizing cardiac arrhythmias is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's circulation, blood pressure, and pulse, and intervene as needed to treat any arrhythmias, shock, or hemorrhage. However, this is not a priority over the client's airway, which is essential for survival.
Choice C reason: This action is incorrect because preventing musculoskeletal disability is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's mobility, sensation, and alignment, and intervene as needed to prevent or treat any fractures, dislocations, or nerve injuries. However, this is not a priority over the client's airway, which is essential for survival.
Choice D reason: This action is incorrect because decreasing intracranial pressure is not the first priority for a client who is unconscious and has trauma to multiple systems. The nurse should assess the client's level of consciousness, pupillary response, and neurological status, and intervene as needed to prevent or treat any increased intracranial pressure, cerebral edema, or brain injury. However, this is not a priority over the client's airway, which is essential for survival.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Home care is the most appropriate resource referral for this client, as they will need skilled nursing care to perform wound care and monitor the healing process. Home care can also provide education and support for the client and their family.
Choice B reason: Assisted living is not a suitable resource referral for this client, as they do not provide skilled nursing care or wound care. Assisted living facilities are designed for clients who need assistance with activities of daily living, but not medical care.
Choice C reason: Long-term care is not a necessary resource referral for this client, as they do not have a chronic or terminal condition that requires 24hour nursing care. Long-term care facilities are intended for clients who are unable to live independently due to physical or cognitive impairments.
Choice D reason: Hospice care is not an appropriate resource referral for this client, as they do not have a terminal illness or a life expectancy of less than six months. Hospice care provides palliative care and comfort measures for clients who are dying and their families.
Correct Answer is D
Explanation
Choice A reason: This statement is false and should not be included in the educational session. TJC is not a for profit organization, but rather an independent, not-for-profit organization that accredits and certifies more than 21,000 health care organizations and programs in the United States.
Choice B reason: This statement is false and should not be included in the educational session. TJC is not an organization that monitors insurance claims, but rather an organization that evaluates health care organizations and inspires them to excel in providing safe and effective care of the highest quality and value.
Choice C reason: This statement is false and should not be included in the educational session. TJC does not provide licensure for health care providers, but rather accreditation and certification for health care organizations and programs. Licensure is the process by which a governmental authority grants permission to individuals or entities to engage in a regulated activity or profession.
Choice D reason: This statement is true and should be included in the educational session. TJC provides accreditation to facilities, which is a voluntary process that involves an external review of an organization's compliance with certain standards and criteria. Accreditation is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards.
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