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 ["A","B","E"]

Explanation

Rationale:

A. Anemia: End-stage kidney disease reduces erythropoietin production by the kidneys, which impairs red blood cell formation in the bone marrow. This often leads to normocytic, normochromic anemia in affected clients.

B. Oliguria: As kidney function declines, urine output diminishes. Oliguria, defined as urine output less than 400 mL/day, is a common clinical feature of advanced kidney failure due to decreased glomerular filtration.

C. Hypotension: Clients with end-stage kidney disease more commonly experience hypertension due to fluid overload and impaired renin-angiotensin-aldosterone regulation. Hypotension may occur during dialysis but is not a typical baseline finding.

D. Bradypnea: Respiratory compensation for metabolic acidosis in kidney disease typically results in tachypnea, not bradypnea. The body increases respiratory rate to blow off excess CO₂ and correct the acid-base imbalance.

E. Edema: Impaired fluid excretion leads to sodium and water retention, resulting in peripheral, facial, or pulmonary edema. This is a hallmark feature of volume overload in chronic kidney disease.

A. Prepare an IV bolus of dextrose 5% in water. B. Administer calcium gluconate IV. C. Position the client supine. D. Administer methylergonovine IM.

Correct Answer is B

Explanation

Rationale:

A. Prepare an IV bolus of dextrose 5% in water: Dextrose in water does not reverse magnesium toxicity. It may be used as a fluid carrier but does not serve as an antidote or address the neuromuscular and cardiac effects of excessive magnesium.

B. Administer calcium gluconate IV: Calcium gluconate is the antidote for magnesium sulfate toxicity. It helps reverse respiratory depression, muscle weakness, and cardiac conduction delays caused by high magnesium levels, making it the immediate intervention.

C. Position the client supine: The supine position can worsen hypotension by decreasing venous return, especially in pregnant clients. Left lateral positioning is generally preferred to improve circulation to vital organs and the fetus.

D. Administer methylergonovine IM: Methylergonovine is used to treat postpartum hemorrhage, but it is contraindicated in clients with hypertension or preeclampsia due to its vasoconstrictive effects. It does not treat magnesium toxicity and could increase blood pressure dangerously.

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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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