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?

Warm blood products prior to administration.

Establish a patent oral airway.

Create a sterile field for wound care.

Administer IV fluids to maintain blood pressure.

Answer and Explanation

The Correct Answer is B

Choice A reason: Warming blood products prevents hypothermia during transfusion but is not the priority in a trauma patient. Airway management takes precedence, as oxygenation is critical to survival. Administering blood products comes later in the trauma algorithm, after securing the airway and stabilizing breathing, making this action secondary.
Choice B reason: Establishing a patent oral airway is the first priority in trauma care, following the ABCs (Airway, Breathing, Circulation). A clear airway ensures oxygenation, critical for preventing hypoxia in a patient with multiple injuries. Without a patent airway, other interventions are ineffective, as oxygen delivery is essential for survival and organ function.
Choice C reason: Creating a sterile field for wound care is important to prevent infection but is not the first priority in a trauma patient. Airway and breathing take precedence, as immediate life-threatening issues like hypoxia or shock must be addressed before wound care, making this action lower in priority.
Choice D reason: Administering IV fluids to maintain blood pressure is part of the circulation phase in trauma care but follows airway and breathing stabilization. Without a patent airway, fluid administration cannot address hypoxia, a primary cause of mortality in trauma. This action is secondary to ensuring airway patency.

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Correct Answer is A

Explanation

Choice A reason: Abdominal pain is a hallmark of ectopic pregnancy, where the embryo implants outside the uterus, often in the fallopian tube. Tissue stretching or rupture causes localized pain, driven by tubal irritation or internal bleeding, requiring urgent evaluation to prevent life-threatening hemorrhage in affected clients.
Choice B reason: Hydramnios, excessive amniotic fluid, occurs in intrauterine pregnancies, not ectopic ones, which lack a uterine gestational sac. Ectopic pregnancies cannot produce amniotic fluid, as implantation occurs outside the uterus, making hydramnios an irrelevant finding in this condition’s pathophysiology.
Choice C reason: Profuse vaginal bleeding is uncommon in ectopic pregnancy, which typically causes spotting or mild bleeding. Heavy bleeding suggests miscarriage or other conditions. Ectopic pregnancies cause internal bleeding, leading to abdominal pain, not profuse vaginal hemorrhage, a key diagnostic distinction.
Choice D reason: Elevated blood pressure is not typical in ectopic pregnancy unless complicated by pain-induced stress or shock. Internal bleeding from ectopic rupture often lowers blood pressure due to hypovolemia, making hypertension an unlikely finding compared to the expected abdominal pain presentation.

A. I will remove gluten from my diet. B. I will remove peanuts from my diet. C. I will avoid bananas. D. I will avoid dairy products.

Correct Answer is C

Explanation

Choice A reason: Gluten removal is unrelated to latex allergy, which involves immune responses to latex proteins. Gluten pertains to celiac disease, not latex-fruit syndrome. Avoiding gluten does not prevent allergic reactions to latex, making this an incorrect understanding of latex allergy management.
Choice B reason: Peanuts are linked to peanut allergies, not latex. Latex allergy involves IgE-mediated reactions to rubber proteins, not peanut proteins. While allergies may coexist, peanuts lack cross-reactivity with latex, making avoidance irrelevant for managing latex allergy symptoms or risks.
Choice C reason: Avoiding bananas is correct due to latex-fruit syndrome, where latex proteins cross-react with banana proteins like chitinases, causing allergic reactions (e.g., itching, anaphylaxis). This understanding ensures clients avoid trigger foods, reducing risk of allergic responses in latex-sensitive individuals.
Choice D reason: Dairy products are not linked to latex allergy, as they lack cross-reactive proteins. Latex reactions stem from exposure to rubber or related plant proteins, not milk. Avoidance is unnecessary, as dairy does not trigger the immunological responses associated with latex allergy.

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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

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