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

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A reason: There are not 4 rights of delegation, but 5 rights of delegation. The 5 rights of delegation are the right task, the right circumstance, the right person, the right direction or communication, and the right supervision or evaluation. The nurse should know and apply these rights when delegating tasks to other members of the health care team.
Choice B reason: The nurse manager is not the only one responsible for delegating nursing tasks during each shift, but the registered nurse (RN) is also responsible for delegating nursing tasks within their scope of practice. The RN should delegate tasks based on the client's needs, the staff's competencies, and the organizational policies. The nurse manager should support and oversee the delegation process, but not assume the sole responsibility for it.
Choice C reason: It is not the duty of the delegate to perform a task without asking questions when it is delegated, but to ask questions or clarify any doubts or concerns before accepting or performing the task. The delegate should communicate effectively with the delegator and ensure that they understand the task, the expected outcome, the time frame, and the resources available. The delegate should also report any problems or issues that arise during or after the task completion.
Choice D reason: I am responsible for ensuring that a delegated task is completed is a correct statement that indicates understanding of delegation. The delegator is accountable for the decision to delegate and the outcome of the task. The delegator should monitor and evaluate the performance and the results of the task, and provide feedback and recognition to the delegate. The delegator should also intervene or take corrective actions if needed.

A. Prevents opioid use B. Increases communication C. Decreases hallucinations D. Reduces restraint use

Correct Answer is D

Explanation

Choice A reason: Preventing opioid use is not a benefit of de-escalation techniques. Opioid use is a complex issue that involves biological, psychological, and social factors, and cannot be prevented by simply deescalating emotional situations. De-escalation techniques may help to calm or soothe someone who is experiencing pain or distress, but they do not address the underlying causes or consequences of opioid use.

Choice B reason: Increasing communication is not a benefit of de-escalation techniques, but a means or a strategy to achieve de-escalation. Communication is an essential skill that helps to deescalate emotional situations by listening, validating, empathizing, and problem solving with the other person. Communication can also help to prevent or reduce conflicts, misunderstandings, and aggression. However, communication is not an outcome or a result of de-escalation, but a process or a tool to facilitate de-escalation.

Choice C reason: Decreasing hallucinations is not a benefit of de-escalation techniques. Hallucinations are perceptual disturbances that involve seeing, hearing, feeling, smelling, or tasting things that are not there. Hallucinations can be caused by various factors, such as mental disorders, neurological conditions, substance use, or medication side effects. De-escalation techniques may help to manage or cope with hallucinations, but they do not treat or eliminate them.

Choice D reason: Reducing restraint use is a benefit of de-escalation techniques. Restraint use is a practice that involves restricting the movement or behavior of a person who poses a risk of harm to themselves or others. Restraint use can have negative effects on the physical and psychological wellbeing of the person, such as injuries, infections, agitation, and trauma. De-escalation techniques can help to avoid or minimize the need for restraint use by resolving or calming emotional situations in a safe and respectful manner.

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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?

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