The nurse in a trauma unit has received 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

Assess the capillary refill

Check pupillary response to light

Check client's response to questions about place and time

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is B

Explanation

Choice A reason: Pulmonary embolism causes chest pain and diaphoresis but typically presents with tachycardia, dyspnea, and normal or non-specific ECG changes, not ST-segment elevation. The latter is specific to myocardial ischemia, making pulmonary embolism less likely. Embolism affects pulmonary circulation, not coronary arteries, which are implicated in the described ECG findings.

Choice B reason: Acute myocardial infarction presents with chest pain, diaphoresis, and ST-segment elevation on ECG, indicating acute coronary artery occlusion leading to myocardial ischemia. This is a life-threatening emergency requiring immediate intervention like percutaneous coronary intervention. The symptoms and ECG findings align with myocardial infarction, making it the most likely diagnosis.

Choice C reason: Pericarditis causes chest pain, often pleuritic, and may cause diaphoresis, but ECG typically shows diffuse ST-segment elevation, not localized as in myocardial infarction. Pericarditis is less likely to cause acute, severe ischemic symptoms. The specific ST elevation and symptoms point to coronary occlusion, not pericardial inflammation.

Choice D reason: Aortic dissection causes severe, tearing chest pain and may cause diaphoresis, but ECG is usually normal or shows non-specific changes, not ST-segment elevation. Dissection affects the aorta, not coronary arteries, making it less likely. The ECG findings and symptoms strongly suggest myocardial infarction over aortic dissection.

A. Fluid intake for the last 24 hours B. Baseline arterial blood gas (ABG) levels C. Blood pressure and heart rate D. Electrocardiogram (ECG) results

Correct Answer is B

Explanation

Choice A reason: Fluid intake over 24 hours affects hydration and cardiovascular status but is not the primary parameter for ventilator weaning. Adequate fluid status supports hemodynamics, but weaning success depends on respiratory parameters like oxygenation and CO2 clearance, which are directly assessed by arterial blood gases, making fluid intake secondary.

Choice B reason: Baseline arterial blood gas (ABG) levels are critical before weaning from a ventilator. ABGs assess oxygenation (PaO2), CO2 levels (PaCO2), and acid-base balance, indicating the patient’s ability to maintain adequate ventilation and gas exchange independently. Normal or stable ABG values are essential to ensure successful weaning without respiratory failure.

Choice C reason: Blood pressure and heart rate reflect cardiovascular stability, which is important during weaning to ensure the patient tolerates increased respiratory effort. However, these are secondary to respiratory parameters. ABGs directly measure lung function, making them the priority to confirm the patient can breathe independently without ventilator support.

Choice D reason: Electrocardiogram (ECG) results assess cardiac rhythm and ischemia, which are relevant in critically ill patients. However, for ventilator weaning, the focus is on respiratory function. ECG abnormalities may warrant attention, but ABGs are the primary parameter to evaluate gas exchange and respiratory adequacy, making ECG less critical in this context.

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The nurse in a trauma unit has received 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?

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Naxlex Comprehensive Predictor Exams

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