A nurse is caring for a client who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on the forehead that is bleeding.
Which of the following is the PRIORITY nursing action at this time?
Establish IV access and start fluid replacement.
Monitor pulse and blood pressure frequently.
Insert a nasogastric tube for decompression.
Keep neck stabilized (Prevent further Injury).
The Correct Answer is D
Choice A rationale
While establishing IV access and fluid replacement are crucial in trauma, they are secondary to ensuring cervical spine stabilization in a patient who is unresponsive after a head-on motor vehicle crash. Uncontrolled movement of an unstable cervical spine can lead to irreversible spinal cord injury, exacerbating neurological deficits or causing paralysis.
Choice B rationale
Monitoring pulse and blood pressure frequently is an important ongoing assessment in a trauma patient to identify shock or other systemic issues. However, in the immediate post-crash scenario with an unresponsive patient, the primary concern is preventing further neurological damage from potential spinal cord injury, making stabilization a higher priority.
Choice C rationale
Inserting a nasogastric tube for decompression might be necessary later in the management of a trauma patient to prevent aspiration or gastric distension. However, it is not the immediate priority action in an unresponsive patient following a head-on collision, where airway, breathing, circulation, and most importantly, cervical spine protection are paramount.
Choice D rationale
In an unresponsive client following a head-on motor vehicle crash, cervical spine injury must be presumed until ruled out. Any movement of the head or neck could further compromise the spinal cord, leading to permanent neurological deficits or even death. Therefore, keeping the neck stabilized using a cervical collar and backboard is the absolute priority to prevent further injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A Venturi mask delivers a precise, fixed concentration of oxygen by mixing oxygen with a set amount of room air. While useful for controlled oxygen delivery in acute settings, it is not the most appropriate long-term home therapy for obstructive sleep apnea, which primarily requires continuous positive airway pressure to maintain airway patency.
Choice B rationale
Continuous Positive Airway Pressure (CPAP) is the gold standard for treating obstructive sleep apnea. It delivers a constant stream of positive pressure air, which acts as a pneumatic splint to keep the upper airway open during sleep, preventing episodes of apnea and hypopnea by maintaining pharyngeal patency.
Choice C rationale
A nasal cannula delivers low-flow oxygen and is generally used for mild hypoxemia. It does not provide the positive pressure needed to keep the airway open during sleep, making it ineffective for treating the underlying airway collapse characteristic of obstructive sleep apnea. It does not address the mechanical obstruction.
Choice D rationale
Bi-level Positive Airway Pressure (BiPAP) delivers different pressures for inspiration and expiration. While also used for sleep apnea, CPAP is typically the first-line and simpler option. BiPAP is often reserved for patients who cannot tolerate CPAP or have coexisting respiratory conditions requiring more sophisticated pressure support, or central apnea.
Correct Answer is D
Explanation
Choice A rationale
Albuterol is a selective beta-2 adrenergic agonist and does not directly suppress the immune response. Corticosteroids are known for their immunosuppressive effects, but Albuterol's primary action is bronchodilation by acting on airway smooth muscle receptors, leading to relaxation and improved airflow without affecting immune cells.
Choice B rationale
While some beta-agonists can have a minor effect on glucose metabolism, leading to slight increases in blood sugar in some individuals, this is not a common or significant side effect associated with typical Albuterol use, especially compared to corticosteroids. Albuterol's primary mechanism involves adenyl cyclase activation, leading to bronchodilation.
Choice C rationale
Mouth sores are not a typical side effect of Albuterol. Oral candidiasis (thrush) can occur with inhaled corticosteroids due to localized immunosuppression and altered oral flora, but Albuterol, being a bronchodilator, does not have this effect. Mouth irritation is possible with any inhaled medication, but not true sores.
Choice D rationale
Albuterol is a beta-2 adrenergic agonist, and while it primarily targets beta-2 receptors in the lungs, it can have some systemic absorption and stimulate beta-1 receptors in the heart, especially with higher doses. This stimulation can lead to an increased heart rate (tachycardia) due to enhanced cardiac contractility and conduction.
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