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.

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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.

A. Increases insulin release from the pancreas, inhibits glucagon secretion, and decreases gastric emptying. B. Reduces glucose production by the liver and enhances insulin sensitivity. C. Slows the absorption of carbohydrate in the small intestine. D. Increases insulin production from the pancreas.

Correct Answer is B

Explanation

Choice A rationale: Metformin does not significantly affect insulin release from the pancreas or glucagon secretion but reduces glucose production by the liver and enhances insulin sensitivity in tissues.

Choice B rationale: Metformin primarily works by reducing glucose production in the liver and improving the body's response to insulin, thereby lowering blood sugar levels.

Choice C rationale: Metformin does not notably slow carbohydrate absorption in the small intestine.

Choice D rationale: Metformin does not directly increase insulin production from the pancreas.

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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

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

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Correct Answer is B

Explanation

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