The client is brought to the ER after falling off a roof and landing on his back. A T4 spinal fracture is diagnosed. The client's blood pressure is 74/40 mmHg, pulse is 55/min, and skin is pink and dry. What of the following nursing actions is a priority?

Determine if blood is present in urine

Perform a neurological assessment

Administer IV normal saline

Perform a 12-lead electrocardiogram

Answer and Explanation

The Correct Answer is C

Choice A rationale: Although important to assess for potential kidney injury, addressing hypotension due to potential spinal shock takes priority.

Choice B rationale: Important for determining any neurological deficits, but addressing hypotension is the initial priority.

Choice C rationale: Hypotension indicates potential spinal shock or hemorrhagic shock, and fluid resuscitation is the immediate priority to stabilize the client's blood pressure.

Choice D rationale: While important for assessing cardiac status, addressing hypotension takes precedence to stabilize the client's condition.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale: Expressive aphasia is a type of non-fluent aphasia that affects the

ability to produce language. It is caused by damage to the anterior part of the left frontal lobe, which is responsible for motor planning and execution of speech. Patients with expressive aphasia can understand language but have difficulty speaking, writing, or naming objects. They often produce short, halting, and grammatically incorrect sentences with word-finding difficulties.

Choice B rationale: this is another term for expressive aphasia. The patient can

understand language but have difficulty speaking, writing, or naming objects. They often produce short, halting, and grammatically incorrect sentences with word-finding difficulties.

Choice C rationale: Global aphasia is a severe form of aphasia that affects both

comprehension and production of language. It is caused by extensive damage to the left hemisphere of the brain, which is dominant for language functions in most people.

Patients with global aphasia have little or no ability to speak, write, read, or understand language.

Choice D rationale: Wernicke's aphasia is a type of receptive aphasia that affects the

comprehension and production of language. It is caused by damage to the posterior part of the left temporal lobe, which is responsible for processing auditory and visual

information. Patients with Wernicke's aphasia can speak fluently but nonsensically, using words that are irrelevant, invented, or distorted. They also have difficulty understanding spoken or written language and following commands.

A. Provide thickened fluids with a straw. B. Listen to bilateral lung and bowel sounds. C. Check the client's Hypoglossal nerve and Vestibulocochlear cranial nerve function. D. Check the client's Glossopharyngeal nerve and Vagus cranial nerve function.

Correct Answer is D

Explanation

Choice A rationale: Providing thickened fluids with a straw is more related to swallowing difficulties and is not the priority in this context.

Choice B rationale: While assessing lung and bowel sounds is important, it's not directly related to offering oral intake after a gastroscopy.

Choice C rationale: Assessing the Hypoglossal nerve and Vestibulocochlear cranial nerve function isn't directly related to offering oral intake post-gastroscopy.

Choice D rationale: Checking the client's Glossopharyngeal nerve and Vagus cranial nerve function is crucial as these nerves play roles in swallowing, taste, and the gag reflex, which are important before allowing oral intake post-gastroscopy.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The client is brought to the ER after falling off a roof and landing on his back. A T4 spinal fracture is diagnosed. The client's blood pressure is 74/40 mmHg, pulse is 55/min, and skin is pink and dry. What of the following nursing actions is a priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A client who is fully awake after a gastroscopy asks the nurse for something to drink. After confirming that liquids are allowed, which assessment action should the nurse consider a priority before offering oral intake?

Correct Answer is D

Explanation

A 16-year-old male presents to the emergency department with right knee pain. Exhibits Complete the statement below: The client is at risk for and the nurse should ?

A nurse notes that a client's serum potassium level is 5.9 mEq/L. The nurse interprets this as an expected finding in the client with:

The medical reports of a client who suffered an accident show injuries at the sixth thoracic vertebra, lack of normal sympathetic outflow, bradycardia and low blood pressure. Which condition does the nurse suspect in the client?

After a breast examination, the nurse is documenting assessment findings that indicate possible breast cancer. Which abnormal findings need to be included as part of the client's electronic medical record? (Select all that apply.)

While performing the genital assessment of a male client, a nurse observes that the client has curvature of the penis. Which condition does the nurse suspect in the client?

The nurse is taking a history of a newly diagnosed Type 2 diabetic who is beginning treatment. Which subjective information is most important for the nurse to note?

A nurse assesses a group of clients who have rheumatoid arthritis (RA). Which client would the nurse see first?

The healthcare provider performs a paracentesis on a client with ascites and 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure?