A nurse witnesses a motor vehicle crash and finds a client who is not breathing. The nurse suspects the client has a cervical vertebrae fracture. Which of the following actions should the nurse take first?
Open the client's airway using the jaw-thrust maneuver to provide oxygenation
Check the client's cranial nerve function by assessing pupils equal, round, reactive to light, and accommodation (PERRLA)
Place the client in a rigid cervical collar
Evaluate the client for brain injury
The Correct Answer is A
A. The first priority in this situation is to open the client's airway using the jaw-thrust maneuver. This technique is preferred for clients with suspected spinal injuries to avoid further spinal cord damage. Ensuring the airway is open and providing oxygenation are immediate life-saving actions.
B. Checking cranial nerve function, including assessing pupils, is important for evaluating neurological status but is not the first action when the client is not breathing. Ensuring the airway is open and providing oxygenation is the priority.
C. While placing the client in a rigid cervical collar is important for stabilizing the spine and preventing further injury, it should be done after ensuring the airway is clear. The immediate concern is to address the client's non-breathing status.
D. Evaluating the client for brain injury is important for overall assessment but is secondary to addressing the immediate life threat of not breathing. Ensuring the airway is open and then stabilizing the spine is the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
A. Osteoarthritis is not associated with hearing loss
B. The client's place of employment as a firearms instructor at a shooting range exposes them to loud noises, which is a well-known risk factor for hearing loss.
C. Gentamycin is an aminoglycoside antibiotic that can be ototoxic, especially when administered in high doses or for prolonged periods, potentially leading to hearing loss.
D. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that has been associated with an increased risk of hearing loss, particularly when taken regularly or in high doses.
E. Bumetanide is a loop diuretic that can also have ototoxic effects, especially when used in conjunction with aminoglycoside antibiotics like gentamycin.
F. Heart failure is not associated with hearing loss
Correct Answer is D
Explanation
A. Vasopressin does not typically increase the client's heart rate; its primary effect is on the kidneys and urine output.
B. Vasopressin generally increases blood pressure by promoting vasoconstriction, not decreases it.
C. Vasopressin will increase, not decrease, urine specific gravity by reducing urine output and concentrating the urine.
D. Vasopressin acts to decrease urine output by increasing water reabsorption in the kidneys, which helps manage diabetes insipidus.
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