A nurse in an emergency department is caring for a client who has a closed head injury. Which of the following actions should the nurse take first?

The correct answer is choice A. A client who has a hip fracture and a new onset of tachypnea.

This client has a high risk of developing a pulmonary embolism, which is a life-threatening condition that requires immediate intervention.

Tachypnea is a sign of respiratory distress and hypoxia, which can indicate a pulmonary embolism.

The nurse should assess this client first and notify the provider.

Choice B is wrong because a client who has diabetes mellitus and an HbA1c of 6.8% is wellcontrolled and does not need urgent attention.

The normal range for HbA1c is 4% to 6%, and the goal for diabetic clients is less than 7%.

Choice C is wrong because a client who has epidural analgesia and weakness in the lower extremities is expected to have some degree of motor impairment due to the medication.

The nurse should monitor the client’s sensation, movement, and pain level, but this is not a priority over choice A. Choice D is wrong because a client who has sinus arrhythmia and is receiving cardiac monitoring is not in immediate danger.

Sinus arrhythmia is a normal variation of heart rhythm that occurs with breathing.

The nurse should observe the client’s vital signs and cardiac rhythm, but this is not a priority over choice A.

The correct answer is choice A. A client who has a hip fracture and a new onset of tachypnea.

This client has a high risk of developing a pulmonary embolism, which is a life-threatening condition that requires immediate intervention.

Tachypnea is a sign of respiratory distress and hypoxia, which can indicate a pulmonary embolism.

The nurse should assess this client first and notify the provider.

Choice B is wrong because a client who has diabetes mellitus and an HbA1c of 6.8% is wellcontrolled and does not need urgent attention.

The normal range for HbA1c is 4% to 6%, and the goal for diabetic clients is less than 7%.

Choice C is wrong because a client who has epidural analgesia and weakness in the lower extremities is expected to have some degree of motor impairment due to the medication.

The nurse should monitor the client’s sensation, movement, and pain level, but this is not a priority over choice A. Choice D is wrong because a client who has sinus arrhythmia and is receiving cardiac monitoring is not in immediate danger.

Sinus arrhythmia is a normal variation of heart rhythm that occurs with breathing.

The nurse should observe the client’s vital signs and cardiac rhythm, but this is not a priority over choice A.

The correct answer is choice C. Holding the client’s eyes shut for a few seconds.

This is because the eyes of a deceased client do not close naturally and may remain open after death. Holding them shut for a few seconds helps to keep them closed and prevent drying of the corneas.

This also gives a more peaceful appearance to the client’s body for the family visit.

Choice A is wrong because crossing the client’s arms across their chest is not a standard postmortem care procedure. It may also interfere with the placement of identification tags on the wrists.

Choice B is wrong because placing the client in a high-Fowler’s position is not necessary or appropriate for postmortem care. The client should be placed in a supine position with the head of the bed elevated to prevent livor mortis (purple discoloration of the skin) on the face.

Choice D is wrong because removing the client’s dentures from their mouth is not recommended for postmortem care. The dentures should be left in place to maintain the shape of the face and prevent the jaw from dropping.

Normal ranges are not applicable for this question as it does not involve any physiological measurements.