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: Genetics is a nonmodifiable risk factor for disease because it is determined by the inherited traits from the parents. Genetics can influence the susceptibility, severity, and progression of certain diseases, such as cancer, diabetes, or cardiovascular disease. The nurse cannot change the client's genetic makeup, but can help the client to manage their condition and prevent complications.
Choice B reason: Sunbathing is a modifiable risk factor for disease because it is influenced by the client's behavior and lifestyle. Sunbathing can increase the exposure to ultraviolet (UV) radiation, which can damage the skin cells and cause skin cancer, premature aging, or sunburn. The nurse can educate the client on the importance of sun protection, such as using sunscreen, wearing protective clothing, and avoiding peak hours of sun exposure.
Choice C reason: Smoking is a modifiable risk factor for disease because it is influenced by the client's behavior and lifestyle. Smoking can harm the lungs, heart, blood vessels, and other organs, and increase the risk of various diseases, such as chronic obstructive pulmonary disease (COPD), lung cancer, or coronary artery disease. The nurse can assist the client in quitting smoking, such as providing counseling, nicotine replacement therapy, or pharmacological interventions.
Choice D reason: Unhealthy diet is a modifiable risk factor for disease because it is influenced by the client's behavior and lifestyle. Unhealthy diet can lead to obesity, malnutrition, or metabolic disorders, and increase the risk of various diseases, such as diabetes, hypertension, or stroke. The nurse can advise the client on the benefits of a balanced diet, such as eating more fruits, vegetables, whole grains, lean proteins, and healthy fats, and limiting the intake of salt, sugar, and saturated fats.
Correct Answer is D
Explanation
Choice A reason: If client is uninsured the ED can decline to render services is not an information that the nurse should include in the teaching. This is a false statement that contradicts the purpose and the provision of EMTALA. According to EMTALA, any hospital that participates in Medicare and has an emergency department must provide an appropriate medical screening examination to anyone who requests it, regardless of their insurance status or ability to pay.
Choice B reason: The ED has the right to refuse to provide client services is not an information that the nurse should include in the teaching. This is a false statement that violates the principle and the requirement of EMTALA. According to EMTALA, any hospital that participates in Medicare and has an emergency department has a duty to provide stabilizing treatment to any individual who has an emergency medical condition or is in active labor, unless an appropriate transfer is arranged.
Choice C reason: The ED can transfer medically unstable clients to other facilities is not an information that the nurse should include in the teaching. This is a false statement that breaches the rule and the regulation of EMTALA. According to EMTALA, any hospital that participates in Medicare and has an emergency department must not transfer an individual who has an emergency medical condition or is in active labor, unless the transfer is requested by the individual or their representative, or the transfer meets certain criteria, such as the benefits outweigh the risks, the receiving facility has agreed to accept the transfer, and the transfer is effected by qualified personnel and equipment.
Choice D reason: Clients must receive a medical screening evaluation (MSE) is an information that the nurse should include in the teaching. This is a true statement that reflects the essence and the standard of EMTALA. According to EMTALA, any hospital that participates in Medicare and has an emergency department must provide an appropriate medical screening examination to anyone who comes to the emergency department and requests examination or treatment for a medical condition, to determine whether or not an emergency medical condition exists
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