Question 28

Choice A reason: Evaluating chest expansion assesses breathing, the second priority in the ABCDE approach. Trauma from a motor vehicle crash may cause rib fractures, pneumothorax, or hemothorax, impairing ventilation. Unequal or absent expansion indicates a life-threatening issue, requiring immediate intervention like chest tube placement to restore adequate respiration.

Choice B reason: Assessing capillary refill evaluates peripheral perfusion, a circulation parameter in the ABCDE approach. While important, it is secondary to airway and breathing. Trauma patients may have shock, but chest injuries affecting ventilation (e.g., pneumothorax) are more immediate threats, making chest expansion the first assessment to ensure respiratory function.

Choice C reason: Checking pupillary response assesses neurological status (disability in ABCDE), relevant for head trauma. However, breathing takes precedence over neurological assessment in trauma patients. Chest injuries can cause rapid respiratory failure, making chest expansion evaluation critical to identify life-threatening conditions like flail chest or pneumothorax before neurological checks.

Choice D reason: Checking orientation to place and time assesses neurological function, part of the disability component in ABCDE. While important in trauma, it is secondary to airway and breathing. Chest injuries from a crash can compromise ventilation, making chest expansion the priority to detect and address immediate respiratory threats before neurological evaluation.

Choice A reason: In DKA, hyperglycemia and ketoacidosis cause fruity breath and Kussmaul respirations (rapid, deep breathing) as the body compensates for acidosis. IV insulin halts ketone production, corrects hyperglycemia, and reverses acidosis, addressing the primary metabolic disturbance. This is the priority intervention to stabilize the client and prevent further acid-base imbalance.

Choice B reason: Oral glucose administration is contraindicated in DKA, as it worsens hyperglycemia. Fruity breath and Kussmaul respirations indicate severe metabolic acidosis from ketone accumulation. Insulin is needed to lower blood glucose and stop ketogenesis, making glucose administration harmful and inappropriate for managing this life-threatening condition.

Choice C reason: IV sodium bicarbonate may correct severe acidosis (pH <7.0) in DKA but is not the first-line intervention. Insulin therapy addresses the root cause by reducing hyperglycemia and ketone production, naturally correcting pH. Fruity breath and respirations indicate ongoing acidosis, making insulin the priority over bicarbonate in initial management.

Choice D reason: Restricting fluid intake is contraindicated in DKA, which causes dehydration from osmotic diuresis. Fruity breath and Kussmaul respirations reflect acidosis and compensatory hyperventilation. IV fluids and insulin are needed to restore volume and correct metabolic imbalances, making fluid restriction harmful and inappropriate for this critical condition.