A nurse is caring for a client who is in the emergency department with multiple traumatic injuries following a motor-vehicle crash. Which of the following actions should the nurse take first?

Establish a patent oral airway.

Remove the client's clothing.

Warm blood products prior to administration.

Assign the client a score on the Glasgow Coma Scale

Answer and Explanation

The Correct Answer is A

Rationale:

A. Establish a patent oral airway: The airway is the highest priority in trauma care, following the ABCs (Airway, Breathing, Circulation). Without a patent airway, the client cannot oxygenate properly, which can quickly become life-threatening.

B. Remove the client's clothing: This helps with full-body assessment and prevention of missed injuries, but it should only be done after ensuring the client’s airway and breathing are stable.

C. Warm blood products prior to administration: While this helps prevent hypothermia during transfusion, warming blood is not the immediate priority in a trauma situation. Circulation support follows airway and breathing in priority.

D. Assign the client a score on the Glasgow Coma Scale: Neurological assessment is important but comes after airway stabilization. The GCS helps evaluate consciousness but should not delay securing the airway in an emergency.

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Correct Answer is D

Explanation

Rationale:

A. "You can lift objects that weigh 15 pounds.": Clients recovering from retinal detachment repair should avoid lifting heavy objects, even as light as 15 pounds. Increased intraocular pressure from straining can compromise the surgical repair.

B. "Pick up items by bending at the waist.": Bending at the waist increases intraocular pressure and should be avoided postoperatively. Clients are advised to bend at the knees and keep their head upright to reduce pressure on the eye.

C. "Avoid reading for 3 days following surgery.": Reading is usually restricted only if it causes eye strain or requires eye movement that could interfere with healing. It is not routinely restricted for a set number of days unless otherwise specified by the surgeon.

D. "Take a stool softener daily.": Straining during bowel movements increases intra-abdominal and intraocular pressure. Stool softeners help prevent straining, making them a useful part of postoperative care after eye surgery to protect the surgical site.

A. Administer Ibuprofen 200 mg PO. B. Elevate the affected forearm with pillows. C. Place a nonadherent dressing on the right knee abrasion. D. Review cast care instructions with the child's parents. E. Apply ice packs to the fingers and along the right forearm. F. Explain the cast application procedure to the child.

Correct Answer is ["A","B","E"]

Explanation

Rationale:

A. Administer Ibuprofen 200 mg PO: The child reports a pain score of 5/10 and is requesting pain medication. The provider has prescribed ibuprofen PRN for this level of pain. Prompt administration supports comfort and reduces inflammation associated with fracture and swelling.

B. Elevate the affected forearm with pillows: Elevation helps reduce edema by promoting venous return and lymphatic drainage. Given the child's worsening edema in the forearm and fingers, this is a priority to minimize complications like compartment syndrome.

C. Place a nonadherent dressing on the right knee abrasion: Although dressing the abrasion is a reasonable intervention, it is not a priority at this stage. The abrasion is not actively bleeding or infected, so attention should remain on managing neurovascular risk and pain.

D. Review cast care instructions with the child's parents: This is an important educational step, but it is not a current priority since the cast has not yet been applied. Priority actions should focus on pain, swelling, and circulation while awaiting casting.

E. Apply ice packs to the fingers and along the right forearm: Ice helps manage pain and inflammation by vasoconstriction, limiting fluid accumulation in tissues. Applying it early post-injury is crucial to controlling swelling in a fractured limb.

F. Explain the cast application procedure to the child: Preparing the child for a future procedure is helpful but not immediately necessary. At this point, pain control and reduction of swelling take precedence to prevent complications and stabilize the injury.

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A nurse is caring for a client who is in the emergency department with multiple traumatic injuries following a motor-vehicle crash. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Explanation

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