The nurse in 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?

Assess the capillary refill.

Check pupillary response to light.

Evaluate chest expansion.

Assess pulses.

Answer and Explanation

The Correct Answer is C

Rationale:
A. Assessing capillary refill evaluates peripheral perfusion but does not take priority over airway and breathing assessment. It is important for circulation assessment but comes after ensuring adequate ventilation.

B. Checking pupillary response provides information about neurological status and potential brain injury, but neurological assessment is not the first priority in trauma unless airway or breathing is compromised.

C. Evaluating chest expansion addresses airway and breathing, which are the first priorities according to the ABCs (Airway, Breathing, Circulation). Multiple injuries from trauma can compromise ventilation due to rib fractures, pneumothorax, or flail chest. Ensuring effective chest expansion and oxygenation is critical to prevent hypoxia and further organ injury.

D. Assessing pulses evaluates circulation and is important in trauma care, but it is secondary to airway and breathing assessment. Hypoxia poses a more immediate threat to life than reduced peripheral perfusion in the early stages of trauma management.

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Correct Answer is C

Explanation

Rationale:
A. Providing good perineal care is important for preventing skin breakdown and infection in clients with spinal cord injuries, but it does not address poikilothermia, which is the inability to regulate body temperature due to impaired autonomic function.

B. Inserting a gastric tube to decompress the stomach is used to manage gastric distention, nausea, or risk of aspiration, but it does not influence the client’s thermoregulation.

C. Keeping the client warm with extra blankets is the most appropriate intervention for poikilothermia. Poikilothermia occurs when the body cannot maintain a stable core temperature because of spinal cord injury that disrupts sympathetic nervous system pathways. Providing external warmth helps prevent hypothermia, reduces stress on the cardiovascular system, and supports overall homeostasis.

D. Stimulating the anal-rectal reflex is used to manage bowel function in spinal cord injury patients, but it does not address the thermoregulatory deficits associated with poikilothermia.

A. WBC 13.8 B. Hgb 14.4 C. Platelets 98 D. Glucose 140 E. Lactate 3.2

Correct Answer is ["A","C","E"]

Explanation

Rationale:
A. WBC 13.8 is correct because leukocytosis indicates infection or systemic inflammatory response, consistent with her urinary symptoms and altered mental status. This lab result supports the need for immediate evaluation and treatment of a suspected urinary tract infection or sepsis.

B. Hgb 14.4 is incorrect because this value is within normal limits for an adult female and does not indicate acute pathology requiring intervention.

C. Platelets 98 is correct because thrombocytopenia (<150,000) may indicate consumption from sepsis or early disseminated intravascular coagulation (DIC). Low platelets increase the risk for bleeding and are clinically significant in a patient with suspected infection.

D. Glucose 140 is incorrect because this value is mildly elevated and may be stress-induced hyperglycemia, which is common in acute illness. While it should be monitored, it does not require immediate intervention.

E. Lactate 3.2 is correct because elevated serum lactate (>2 mmol/L) indicates tissue hypoperfusion and risk of severe sepsis or septic shock. This is a critical finding requiring urgent recognition and intervention, such as fluid resuscitation, antibiotics, and close hemodynamic monitoring.

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The nurse in 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

A client with a spinal cord injury is exhibiting poikilothermia. Which of the following would be appropriate to include in this client's plan of care?

Correct Answer is C

Explanation

Correct Answer is ["A","C","E"]

Explanation

Organ perfusion depends on mean arterial pressure. All are true regarding mean arterial pressure except:

Administering Dopamine (Inotropin) at 2 mcg/kg/minute results in:

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