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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Polyuria, excessive urine output, typically leads to potassium loss, causing hypokalemia, not hyperkalemia. In conditions like diabetes insipidus, increased urination reduces serum potassium as the kidneys excrete more fluid and electrolytes. Elevated potassium is more associated with reduced renal excretion, as in kidney failure, not polyuria.
Choice B reason: Creatinine levels increase in acute kidney injury due to reduced glomerular filtration, impairing the kidneys’ ability to clear creatinine, a muscle metabolism byproduct. Decreased creatinine levels are rare and may reflect low muscle mass, not kidney injury, making this statement incorrect as it contradicts the pathophysiology of renal impairment.
Choice C reason: Specific gravity is increased in hypovolemia, as the kidneys conserve water, producing concentrated urine (high specific gravity, >1.020). Decreased specific gravity occurs in conditions like diabetes insipidus, where dilute urine is produced. This statement is incorrect, as hypovolemia leads to higher, not lower, urine specific gravity.
Choice D reason: Blood urea nitrogen (BUN) increases in dehydration due to reduced renal perfusion, causing the kidneys to reabsorb urea to conserve water. This elevates serum BUN levels, often with a normal creatinine, reflecting prerenal azotemia. This statement correctly aligns with the pathophysiology of dehydration’s effect on renal laboratory values.
Correct Answer is C
Explanation
Choice A reason: Esophageal intubation results in no chest wall expansion bilaterally, as air enters the stomach, not the lungs. The client’s unilateral absence of left-sided expansion suggests air is entering the right lung, indicating the tube is in the trachea but malpositioned, not in the esophagus, which would affect both sides.
Choice B reason: Vocal cord infection, or laryngitis, may cause hoarseness or airway swelling but does not cause unilateral chest wall expansion failure. This finding indicates a mechanical issue with ventilation distribution, such as tube malposition. Infection affects mucosal function, not lung expansion, making this an unlikely cause of the observed symptom.
Choice C reason: Movement of the endotracheal tube into the right main bronchus causes right-sided ventilation and left-sided collapse, resulting in absent left chest wall expansion. This malposition, common due to the right bronchus’s straighter anatomy, leads to unilateral ventilation, matching the client’s presentation and requiring urgent repositioning to restore bilateral lung function.
Choice D reason: Tongue blockage of the endotracheal tube is unlikely, as the tube is placed beyond the oral cavity. Even if obstructed, it would affect both lungs, not just the left. The unilateral absence of expansion points to tube malposition in the right bronchus, selectively ventilating one lung, not a tongue-related obstruction.
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