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
Vigorous coughing or nose blowing increases pressure in the middle ear, potentially dislodging the stapes prosthesis, interfering with healing, and increasing risk of complications like vertigo or auditory damage.
Choice B rationale
Packing with dry dressing is contraindicated because it may trap moisture and increase infection risk. If drainage occurs, sterile measures are taken to assess and manage infection without creating ideal conditions for pathogens.
Choice C rationale
Irrigation of the ear canal risks introducing pathogens or disrupting the surgical area. Post-surgery, maintaining a dry environment helps reduce infection and promote proper healing.
Choice D rationale
Though bedrest may be recommended initially, prolonged immobility isn't essential unless specific complications arise. Movement minimizes risks of clot formation and encourages circulation, aiding recovery.
Correct Answer is D
Explanation
Choice A rationale
Clopidogrel is an antiplatelet agent that prevents platelet aggregation but does not affect arrhythmias. It reduces clot formation risk, which is critical for patients with a history of TIA or stroke.
Choice B rationale
Clopidogrel does not lower blood pressure. It works by inhibiting platelet aggregation to prevent thrombus formation, not addressing the mechanisms of hypertension or blood pressure control.
Choice C rationale
Clopidogrel does not directly affect peripheral artery disease symptoms, such as leg pain. It is used to reduce the risk of thrombotic events like strokes and heart attacks by preventing platelet aggregation.
Choice D rationale
Clopidogrel inhibits platelet aggregation by blocking the ADP receptor on platelets, reducing the risk of clot formation. This is crucial for preventing ischemic events in patients with a history of TIA.
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