A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?

Preventing musculoskeletal disability

Airway protection

Stabilizing cardiac arrhythmias

Decreasing intracranial pressure

Answer and Explanation

The Correct Answer is B

Choice A Reason: Preventing musculoskeletal disability is important, but not the priority focus of care. The nurse should first assess and manage the client's life-threatening injuries, such as airway obstruction, bleeding, shock, or brain injury.

Choice B Reason: Airway protection is the priority focus of care for a client with multiple system trauma. The nurse should ensure that the client has a patent airway and adequate ventilation, as any compromise in these areas can quickly lead to hypoxia, respiratory failure, and death.

Choice C Reason: Stabilizing cardiac arrhythmias is also important, but not the priority focus of care. The nurse should monitor the client's cardiac rhythm and treat any arrhythmias that may occur, but only after securing the airway and breathing.

Choice D Reason: Decreasing intracranial pressure is another important goal, but not the priority focus of care. The nurse should assess the client's neurological status and intervene to prevent or reduce increased intracranial pressure, such as elevating the head of the bed, maintaining normothermia, and administering osmotic diuretics. However, these measures are secondary to ensuring adequate oxygenation and perfusion.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A Reason: Urine output is not a finding that should decrease with adequate ﬂuid replacement. On the contrary, urine output should increase as the ﬂuid therapy restores the renal perfusion and function. The nurse should monitor the urine output and ensure that it is at least 0.5 mL/kg/hr for adults and 1 mL/kg/hr for children.

Choice B Reason: Heart rate is a finding that should decrease with adequate ﬂuid replacement. A high heart rate is a sign of hypovolemia, which occurs when the burn injury causes ﬂuid loss from the intravascular space. The nurse should monitor the heart rate and expect it to decrease as the ﬂuid therapy replenishes the blood volume and improves the cardiac output.

Choice C Reason: Weight is not a finding that should decrease with adequate ﬂuid replacement. On the contrary, weight may increase as the ﬂuid therapy restores the hydration status and corrects the ﬂuid deficit. The nurse should monitor the weight and compare it with the pre-burn weight to evaluate the ﬂuid balance.

Choice D Reason: Blood pressure is not a finding that should decrease with adequate ﬂuid replacement. On the contrary, blood pressure may increase as the ﬂuid therapy restores the vascular tone and improves the tissue perfusion. The nurse should monitor the blood pressure and expect it to increase as the ﬂuid therapy compensates for the ﬂuid loss.

A. A client who is post-coronary artery bypass graft (CABG), has total cholesterol of 318 mg/dL, and is prescribed atorvastatin B. A client who has pneumonia, a WBC count of 11,500/mm³, and is prescribed piperacillin C. A client who has renal failure, a serum potassium of 5.8 mEq/L, and is prescribed sodium polystyrene sulfonate D. A client who has anemia, hemoglobin of 11 g/dL, and is prescribed epoetin alfa

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because a client who is post-CABG and has high cholesterol is not in immediate danger, as atorvastatin is a long-term medication that lowers cholesterol and prevents cardiovascular complications.

Choice B Reason: This is incorrect because a client who has pneumonia and a slightly elevated WBC count is not in immediate danger, as piperacillin is an antibiotic that treats bacterial infections.

Choice C Reason: This is correct because a client who has renal failure and a high serum potassium level is in immediate danger, as sodium polystyrene sulfonate is an emergency medication that lowers potassium and prevents cardiac arrhythmias.

Choice D Reason: This is incorrect because a client who has anemia and a mild hemoglobin deficiency is not in immediate danger, as epoetin alfa is a long-term medication that stimulates red blood cell production and improves oxygen delivery.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who was admited with a severe burn injury and is receiving IV ﬂuid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate ﬂuid replacement?

Correct Answer is B

Explanation

A nurse is preparing to administer medications to four clients. The nurse should administer medications to which of the following clients first?

Correct Answer is C

Explanation

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

A nurse in the emergency department is caring for a client who has sustained a head injury. The nurse notes the client's IV ﬂuids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client?

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification?

Here is the edited text: A nurse is caring for a client who has a traumatic brain injury. The nurse notes that the client has a widening pulse pressure. Which of the following actions should the nurse take?

A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions?

A nurse is assessing a client in the oliguric phase of acute kidney injury. Which of the following findings should the nurse expect?