The nurse in the emergency department is caring for a client with multiple injuries following a motor vehicle crash. The client lost consciousness. has an open fracture of the left tibia, and active bleeding at the fracture site. What is the priority nursing action?

Prepare for immediate surgery to repair the open fracture

Assess for pulses in the upper and lower extremities

Place a sterile pressure dressing on the open fracture

Maintain C-spine immobilization

Answer and Explanation

The Correct Answer is D

A. Prepare for immediate surgery to repair the open fracture
Surgery may be necessary, but it is not the immediate priority. The focus should be on stabilizing the client and preventing further injury.

B. Assess for pulses in the upper and lower extremities
Assessing circulation is important but is not the most immediate life-saving intervention. First, the client must be stabilized and bleeding controlled.

C. Place a sterile pressure dressing on the open fracture
While controlling bleeding is important, spinal immobilization takes precedence in trauma cases to prevent potential spinal cord injury.

D. Maintain C-spine immobilization
In a trauma patient with loss of consciousness, cervical spine injury must be assumed. Immobilization prevents further damage while other interventions are performed.

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Correct Answer is B

Explanation

A. Wearing sunglasses while symptomatic

Sunglasses reduce photophobia, but they do not prevent corneal damage from dryness.

B. Applying an eye patch before sleep

Bell's palsy affects cranial nerve VII (facial nerve), leading to incomplete eye closure. This can cause corneal abrasions and dryness. An eye patch at night prevents corneal injury.

C. An antihistamine eye drop

Antihistamine eye drops may dry out the eye further, worsening the risk of corneal injury.

D. Antibiotic ophthalmic ointment

Antibiotics are not necessary unless an infection is present. Lubricating drops or artificial tears are more appropriate.

A. Causative agent and duration of exposure B. Depth of burn C. Anatomical location of burns on the body D. Total Body Surface Area (TBSA) percentage E. Time of day burn occurred

Correct Answer is ["A","B","C","D"]

Explanation

A. Causative agent and duration of exposure – Chemical, electrical, or thermal burns differ in severity.

B. Depth of burn – Superficial, partial-thickness, and full-thickness burns determine severity.

C. Anatomical location – Burns over joints, face, or perineum have higher morbidity.

D. Total Body Surface Area (TBSA) percentage – Used to estimate fluid resuscitation needs (e.g., Parkland formula).

E. Time of day burn occurred – Time does not affect burn severity.

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The nurse in the emergency department is caring for a client with multiple injuries following a motor vehicle crash. The client lost consciousness. has an open fracture of the left tibia, and active bleeding at the fracture site. What is the priority nursing action?

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Naxlex Comprehensive Predictor Exams

Due to cranial nerve involvement in Bell's palsy, which of the following would prevent a potential complication from the disorder?

Correct Answer is B

Explanation

For the nurse to correctly classify the severity of a burn injury of a client, what must be assessed? (Select All that Apply.)

Correct Answer is ["A","B","C","D"]

Explanation

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