A patient is brought to the emergency department after sustaining injuries in a severe car crash. The patient's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the patient is cyanotic. What action by the nurse is the priority?

Administer fluids.

Give pain medications as ordered.

Prepare the patient for a CT scan.

Prepare to assist with intubation.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Administering fluids is important for maintaining hemodynamic stability, but it is not the immediate priority for a patient with compromised respiration and low oxygen saturation.

Choice B reason:

Giving pain medications is necessary for patient comfort but is not the priority in a situation where the patient's respiratory status is severely compromised.

Choice C reason:

Preparing the patient for a CT scan can help assess internal injuries but is not the immediate priority when the patient is cyanotic and has low oxygen saturation. Immediate respiratory support is required first.

Choice D reason:

Preparing to assist with intubation is the priority action. The patient's oxygen saturation is critically low, and the chest wall is not moving normally, indicating potential respiratory failure. Intubation and mechanical ventilation are necessary to secure the airway and provide adequate oxygenation.

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Correct Answer is A

Explanation

Choice A reason:

Arterial Blood Gas (ABG) analysis is the best method to determine the effectiveness of treatments in a client receiving mechanical ventilation. ABGs provide direct information about the patient's oxygenation, ventilation, and acid-base status, which are critical in managing acute respiratory failure.

Choice B reason:

While blood pressure is important for overall patient monitoring, it does not provide specific information about the effectiveness of ventilation and respiratory status. It is more related to hemodynamic stability.

Choice C reason:

Capillary refill can provide some information about peripheral perfusion but is not specific enough to assess the effectiveness of mechanical ventilation or respiratory treatments.

Choice D reason:

Heart rate is a vital sign that can indicate the patient's overall condition but does not specifically assess the effectiveness of ventilation or respiratory treatments. It should be considered along with other more specific respiratory assessments.

A. Apply tight-fitting clothing B. Complete frequent skin checks C. Initiate a bowel regimen program D. Insert an indwelling Foley catheter E. Restrict all patient visitors

Correct Answer is ["B","C","D"]

Explanation

Choice A reason:

Applying tight-fitting clothing is not recommended for patients at risk of autonomic dysreflexia. Tight clothing can be a trigger for this condition by causing discomfort and potentially leading to an exaggerated autonomic response.

Choice B reason:

Completing frequent skin checks is crucial in preventing autonomic dysreflexia. Skin irritation, pressure sores, and other integumentary issues can trigger autonomic responses. Regular assessments help in early identification and prevention of potential irritants.

Choice C reason:

Initiating a bowel regimen program is essential for preventing autonomic dysreflexia. Constipation or bowel distension can be potent triggers for this condition. A consistent bowel program helps in managing and preventing these issues.

Choice D reason:

Inserting an indwelling Foley catheter is recommended to manage bladder distention, a common trigger of autonomic dysreflexia. Continuous bladder drainage prevents overdistention and reduces the risk of triggering autonomic responses.

Choice E reason:

Restricting all patient visitors is unnecessary for preventing autonomic dysreflexia. While a calm environment can be beneficial, visitor restriction is not directly related to managing the risk of this specific condition.

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A patient is brought to the emergency department after sustaining injuries in a severe car crash. The patient's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the patient is cyanotic. What action by the nurse is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method to determine the effectiveness of the current treatments?

Correct Answer is A

Explanation

The nurse is caring for a mechanically ventilated spinal cord injury patient in the ICU. To avoid the complication of autonomic dysreflexia, the nurse plans to implement the following orders:

Correct Answer is ["B","C","D"]

Explanation

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