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
Explanation
A. A face shield is necessary when there is a risk of splashes, but not required for simply checking a pulse.
B. Clean gloves are appropriate for contact with the client or the wound, as MRSA is transmitted through direct contact. This prevents contamination while assessing the client.
C. Sterile gloves are not required for checking a pulse unless performing a sterile procedure.
D. An N95 respirator mask is used for airborne precautions, not necessary for MRSA, which is contact-transmitted.
Correct Answer is A
Explanation
A. Levothyroxine is a thyroid hormone replacement used to treat hypothyroidism. Symptoms such as tremors, nervousness, and insomnia can indicate that the dose is too high, as these are signs of hyperthyroidism.
B. Weight loss is not a typical reason to notify the healthcare provider unless it is accompanied by other symptoms of hyperthyroidism. Monitoring for symptoms of excessive thyroid hormone can be more critical.
C. Levothyroxine does not typically require monitoring for an increased risk of bleeding. This medication primarily affects thyroid hormone levels and does not have a direct impact on blood clotting.
D. Levothyroxine increases, rather than decreases, thyroid hormone levels. It is used to replace or supplement thyroid hormone in the case of hypothyroidism, not to decrease thyroid hormone production.
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