A nurse is the first person on the scene of a motor vehicle accident.
The victim was the driver and is in the driver's seat unconscious.
The driver is breathing, has a pulse, and has minor lacerations on the head and face.
What action should the nurse implement first?
Stabilize the cervical spine until help arrives.
Control any external bleeding.
Use the head tilt chin lift method to maintain the airway.
Do not move the victim from the accident.
The Correct Answer is A
Choice A rationale
Stabilizing the cervical spine prevents further spinal injury in case of vertebral damage, which is a priority when managing trauma patients until specialized medical care becomes available.
Choice B rationale
While controlling bleeding is essential, it is secondary to stabilizing the cervical spine since the airway and neurological protection take precedence in trauma protocols.
Choice C rationale
The head tilt chin lift method should not be used if cervical spine injury is suspected, as it may exacerbate potential damage to the vertebrae or spinal cord.
Choice D rationale
While not moving the victim is critical, stabilization of the cervical spine is the primary intervention to prevent further injury before emergency assistance arrives.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Metoprolol decreases cardiac workload by reducing heart rate and myocardial oxygen demand. A heart rate of 62 is within normal limits, demonstrating effective beta-blocker action and improved cardiac efficiency.
Choice B rationale
Lying flat without difficulty breathing reflects improved respiratory status, which is more related to pulmonary management, not directly indicative of reduced cardiac workload or beta-blocker efficacy.
Choice C rationale
Absence of dyspnea after climbing stairs suggests improved physical fitness but does not directly measure the cardiac effects of metoprolol, which targets heart rate reduction and myocardial oxygen use.
Choice D rationale
Weight loss is related to overall health improvement or dietary changes rather than specific effects of metoprolol, which primarily impacts heart rate and cardiac oxygen consumption.
Correct Answer is C
Explanation
Choice A rationale
Monitoring frequency of urination indicates bladder involvement, often related to cystitis. However, it does not indicate ascending progression to the kidneys, which is more severe and requires additional symptoms.
Choice B rationale
Dysuria, or painful urination, typically signifies lower urinary tract infection rather than progression to upper urinary tract infection, such as pyelonephritis. It is not specific to kidney involvement.
Choice C rationale
Flank pain and fever are hallmark symptoms of pyelonephritis, indicating ascending progression of infection from the bladder to the kidneys. These symptoms signal systemic involvement and require immediate medical attention.
Choice D rationale
Pyuria and hematuria are signs of bladder infection but do not indicate progression to kidney infection. These are specific to inflammation or infection in the lower urinary tract.
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