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 C

Explanation

Rationale:

A. Instruct the parent to give 5 mcg of vitamin D daily: While vitamin D supplementation is recommended for breastfed infants, this advice does not address the inappropriate introduction of cow’s milk, which can cause complications such as intestinal bleeding and iron deficiency in infants under 12 months.

B. Instruct the parent to give the infant water every 3 hr between feedings: Offering water to infants under 6 months is discouraged, as it can displace essential nutrients from breast milk or formula and increase the risk of water intoxication due to immature kidneys.

C. Advise the parent to avoid giving cow's milk to the infant prior to 1 year of age: Cow's milk is not suitable for infants under 12 months because it lacks adequate iron and nutrients, and its high protein content can irritate the immature kidneys and intestinal lining.

D. Recommend the parent mix the milk with rice cereal for feedings: Mixing cow’s milk with cereal does not resolve its nutritional inadequacy or potential risks. Introducing solids and allergenic foods should follow developmental readiness and established pediatric guidelines.

A. Change gloves after contact with infectious material. B. Wear an N95 respirator when providing care. C. Wear a gown when providing care. D. Remove the thermometer from client's room for use on another client. E. Wash hands with an alcohol based cleaner.

Correct Answer is ["A","C"]

Explanation

Rationale:

A. Change gloves after contact with infectious material: Gloves must be changed after contact with infectious material to prevent cross-contamination. C. difficile spores can survive on surfaces and be transferred if gloves are not properly changed between tasks or patients.

B. Wear an N95 respirator when providing care: An N95 respirator is not required for C. difficile, as it is transmitted via the fecal-oral route through spores, not by airborne particles. Standard and contact precautions not airborne are appropriate for this infection.

C. Wear a gown when providing care: Wearing a gown is essential when caring for a client with C. difficile, as the spores can contaminate clothing and surfaces. Contact precautions require both gloves and gowns for direct care.

D. Remove the thermometer from client's room for use on another client: Equipment used for a client with C. difficile should remain dedicated to that client to prevent environmental contamination. Sharing items between patients increases the risk of spreading spores.

E. Wash hands with an alcohol-based cleaner: Alcohol-based hand sanitizers are ineffective against C. difficile spores. Hands should be washed with soap and water, which is the only effective method for removing these resilient organisms.

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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?

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