The nurse in a trauma unit has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?
Evaluate chest expansion.
Check pupillary response to light.
Check the client's response to questions about place and time.
Assess the capillary refill.
The Correct Answer is A
Choice A: Evaluating chest expansion is the first action that the nurse should take, because it assesses the client's respiratory status and potential for pneumothorax, which is a life-threatening condition that can result from chest trauma. The nurse should compare the movement of both sides of the chest and listen for breath sounds.
Choice B: Checking pupillary response to light is an important action, but not the first one, because it assesses the client's neurological status and potential for brain injury. The nurse should observe the size, shape, and symmetry of the pupils and their reaction to light.
Choice C: Checking the client's response to questions about place and time is another important action, but not the first one, because it assesses the client's level of consciousness and orientation. The nurse should ask the client simple questions such as their name, date, and location.
Choice D: Assessing the capillary refill is a less important action, and not the first one, because it assesses the client's peripheral circulation and tissue perfusion. The nurse should press on the client's nail beds or fingertips and observe how quickly the color returns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because cognitive impairment that decreases over several months post-injury is more likely to occur in a client who has a diffuse axonal injury, which is a widespread damage to the brain's white mater.
Choice B Reason: This is incorrect because neurologic deficits that increase up to 2 weeks post-injury are more likely to occur in a client who has a subdural hematoma, which is a collection of blood between the dura and the arachnoid membranes.
Choice C Reason: This is incorrect because a change in the level of consciousness that develops over 48 hr is more likely to occur in a client who has an intracerebral hematoma, which is a collection of blood within the brain tissue.
Choice D Reason: This is correct because a lucid period followed by an immediate loss of consciousness is a typical manifestation of an epidural hematoma, which is a collection of blood between the skull and the dura. The lucid period occurs when the initial bleeding stops and the client regains consciousness. The immediate loss of consciousness occurs when the bleeding resumes and causes increased intracranial pressure.
Correct Answer is B
Explanation
Choice A Reason: This choice is incorrect because oral hypoglycemic medications are not effective for treating DKA. Oral hypoglycemic medications are drugs that lower the blood glucose level by stimulating insulin secretion or increasing insulin sensitivity. They may be used for clients who have type 2 diabetes mellitus, but they do not work for clients who have type 1 diabetes mellitus or DKA.
Choice B Reason: This choice is correct because 0.9% sodium chloride IV bolus is an effective treatment for DKA. 0.9% sodium chloride is an isotonic solution that contains the same concentration of solutes as blood plasma. It may be used for clients who have fluid loss, dehydration, or shock. In DKA, the body breaks down fat for energy due to insulin deficiency or resistance, resulting in high levels of ketones and acids in the blood. This causes osmotic diuresis, dehydration, electrolyte imbalance, and metabolic acidosis. Therefore, administering 0.9% sodium chloride IV bolus can help to restore fluid volume and correct electrolyte imbalance.
Choice C Reason: This choice is incorrect because dextrose 5% in 0.45% sodium chloride is not indicated for treating DKA. Dextrose 5% in 0.45% sodium chloride is a hypertonic solution that contains more solutes than blood plasma. It may be used for clients who have hyponatremia, cerebral edema, or malnutrition, but it can worsen hyperglycemia and osmotic diuresis in clients who have DKA.
Choice D Reason: This choice is incorrect because glucocorticoid medications are not indicated for treating DKA. Glucocorticoid medications are drugs that mimic the effects of cortisol, a hormone that regulates stress response and inflammation. They may be used for clients who have allergic reactions, asthma, or autoimmune diseases, but they can increase blood glucose levels and inhibit insulin action in clients who have DKA.
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