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.

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Correct Answer is B

Explanation

Choice A Reason: This is incorrect because the client is not in deep coma, as the Glasgow Coma Scale (GCS) score ranges from 3 to 15, with 3 being the lowest possible score and indicating deep coma or death.

Choice B Reason: This is correct because the client needs total nursing care, as the GCS score of 6 indicates a severe brain injury and a very low level of consciousness. The client may only open his eyes to pain, make incomprehensible sounds, and have abnormal ﬂexion to pain.

Choice C Reason: This is incorrect because the client is not alert and oriented, as the GCS score of 6 indicates a severe brain injury and a very low level of consciousness. The client may not be able to follow commands, answer questions, or recognize people or places.

Choice D Reason: This is incorrect because the client is not responding to verbal stimuli, as the GCS score of 6 indicates a severe brain injury and a very low level of consciousness. The client may only respond to painful stimuli, such as pinching or squeezing.

A. Increased urine output B. Decreased blood glucose level C. Decreased blood pressure D. Increased heart rate

Correct Answer is A

Explanation

Choice A Reason: Dobutamine is a positive inotropic agent that increases the contractility of the heart and improves cardiac output. This leads to increased renal perfusion and urine output, which reduces the ﬂuid overload and edema associated with heart failure. Therefore, this choice is correct.

Choice B Reason: Dobutamine does not have a direct eﬀect on blood glucose level. It may cause hyperglycemia as a side eﬀect, but this is not an indication of its eﬀectiveness. Therefore, this choice is incorrect.

Choice C Reason: Dobutamine may cause a slight decrease in blood pressure due to vasodilation, but this is not its main therapeutic eﬀect. A significant decrease in blood pressure may indicate hypovolemia, hypotension, or shock, which are adverse eﬀects of dobutamine. Therefore, this choice is incorrect.

Choice D Reason: Dobutamine also has a positive chronotropic eﬀect, which means it increases the heart rate. However, this is not a desired outcome for a client with heart failure, as it increases the oxygen demand of the heart and may worsen the condition. Therefore, this choice is incorrect.

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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 assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?

Correct Answer is B

Explanation

A nurse in the ICU is caring for a client who has heart failure and is receiving a dobutamine drip. The nurse should identify that which of the following findings indicates that the medication is eﬀective?

Correct Answer is A

Explanation

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