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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Eddie Bernice Johnson is not the founder of the American Red Cross, but rather a contemporary politician and nurse. She is the first registered nurse elected to the United States Congress, where she represents Texas's 30th congressional district.
Choice B reason: Florence Nightingale is not the founder of the American Red Cross, but rather the founder of modern nursing. She is known for her pioneering work in nursing education, research, and reform, especially during the Crimean War, where she improved the sanitary conditions and reduced the mortality rate of wounded soldiers.
Choice C reason: Dorothea Dix is not the founder of the American Red Cross, but rather a social reformer and advocate for the mentally ill. She is known for her efforts to improve the treatment and care of the mentally ill in the United States and Europe, and for organizing nurses during the American Civil War.
Choice D reason: Clara Barton is the founder of the American Red Cross, as well as a nurse and humanitarian. She is known for her service as a nurse during the American Civil War, where she tended to the wounded on the battlefield and distributed supplies. She also founded the American Red Cross in 1881, after learning of the International Red Cross in Switzerland, and led the organization for 23 years.
Correct Answer is A
Explanation
Choice A reason: Critical thinking is a component of clinical decision-making that the nurse should use to make an evidence based decision. Critical thinking is the process of applying logic, reasoning, analysis, and evaluation to the information and evidence that is available. Critical thinking helps the nurse to identify and question assumptions, biases, and gaps in the data, and to draw valid and reliable conclusions based on the best available evidence.
Choice B reason: Clinical judgement is not a component of clinical decision-making, but an outcome of clinical decision-making. Clinical judgement is the result of applying critical thinking and clinical reasoning to the data and evidence that is gathered and interpreted. Clinical judgement is the expression of the nurse's decision or opinion about the client's situation, needs, and interventions.
Choice C reason: Concept mapping is not a component of clinical decision-making, but a tool or a strategy that can facilitate clinical decision-making. Concept mapping is a visual representation of the relationships among concepts, data, and evidence that are relevant to the client's situation. Concept mapping can help the nurse to organize, synthesize, and analyze the information, and to identify patterns, themes, and gaps in the data.
Choice D reason: Clinical reasoning is not a component of clinical decision-making, but a process that is involved in clinical decision-making. Clinical reasoning is the cognitive process that the nurse uses to collect, process, interpret, and integrate the data and evidence that is available. Clinical reasoning helps the nurse to make sense of the client's situation, needs, and responses, and to select the appropriate interventions and actions.
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