A patient has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?

Apply oxygen at 100%.

Assess the heart rate.

Ensure a patent airway.

Start two large-bore IV lines.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Applying oxygen at 100% is an important step in managing a patient with a life-threatening chest injury. However, ensuring a patent airway is the first priority, as it is crucial to maintain airway patency to facilitate oxygen delivery. Without an open airway, oxygen administration would be ineffective.

Choice B reason:

Assessing the heart rate is part of the initial assessment in emergency care. However, the priority is to ensure a patent airway, as a compromised airway can lead to hypoxia and rapid deterioration of the patient's condition. Heart rate assessment can follow once airway patency is confirmed.

Choice C reason:

Ensuring a patent airway is the top priority in the emergency management of a patient with a life-threatening chest injury. Airway patency is essential for effective ventilation and oxygenation. If the airway is obstructed, the patient cannot receive oxygen or expel carbon dioxide, leading to life-threatening complications.

Choice D reason:

Starting two large-bore IV lines is important for fluid resuscitation and medication administration. However, the primary focus should be on ensuring a patent airway, as immediate airway management is critical to the patient's survival in the acute phase of a life-threatening chest injury.

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Correct Answer is B

Explanation

Choice A reason:

Loss of consciousness greater than 30 minutes following injury can occur in various types of head injuries but is not specific to epidural hematomas.

Choice B reason:

Lucid intervals followed by momentary unconsciousness are characteristic of epidural hematomas. Patients with epidural hematomas often experience a period of lucidity following the initial loss of consciousness, followed by a rapid decline in mental status as the hematoma enlarges and increases intracranial pressure.

Choice C reason:

Memory loss of the prior day's activities can occur with various head injuries but is not specific to epidural hematomas.

Choice D reason:

Amnesia of the injury event is common in head injuries but is not specific to epidural hematomas. The hallmark of epidural hematomas is the pattern of lucid intervals followed by rapid deterioration.

A. Autonomic dysreflexia B. Ischemia C. Edema D. Axial loading E. Hemorrhage

Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason:

Autonomic dysreflexia is a serious condition that can occur in individuals with spinal cord injuries, particularly those at or above the T6 level. It is a secondary injury mechanism that results from the autonomic nervous system's abnormal response to stimuli below the level of injury, leading to severe hypertension and other complications.

Choice B reason:

Ischemia, or reduced blood flow, is a common cause of secondary injury following a spinal cord injury. It can result from initial trauma or subsequent swelling and vascular damage, leading to further cell death and tissue damage.

Choice C reason:

Edema, or swelling, is another cause of secondary injury in spinal cord injuries. The inflammatory response to injury can cause fluid accumulation, increasing pressure within the spinal column and exacerbating damage to spinal cord tissues.

Choice D reason:

Axial loading is a primary mechanism of spinal cord injury, not a secondary injury cause. It refers to the vertical force applied along the axis of the spine, typically resulting from falls or direct blows, leading to compression and potential fractures.

Choice E reason:

Hemorrhage, or bleeding, is a significant cause of secondary injury in spinal cord trauma. It can result from blood vessel damage at the injury site, leading to increased pressure, further tissue damage, and impaired blood flow.

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A patient has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient presents to the emergency department with signs of an epidural hematoma. Which manifestation is characteristic of this type of hematoma?

Correct Answer is B

Explanation

A nursing student studying spinal cord injury recognizes all of the following to be causes of secondary injuries:

Correct Answer is ["A","B","C","E"]

Explanation

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