The nurse is admitting a client to the emergency department (ED) who was in a motor vehicle collision and has multiple traumatic injuries. Which of the following assumptions is a priority guiding principle for the nurse in this situation?
That there is a high potential for acute respiratory distress syndrome
That the risk of survival is likely very low
That there is likely for multiple bone fractures
That a spinal cord injury exists until proven otherwise
The Correct Answer is D
A. That there is a high potential for acute respiratory distress syndrome is incorrect because although ARDS can occur after severe trauma, it is not the immediate guiding principle during initial emergency assessment. The primary focus is stabilization and prevention of further injury.
B. That the risk of survival is likely very low is incorrect because assumptions about survival do not guide safe clinical care. Trauma management is focused on systematic assessment and rapid intervention to improve survival outcomes.
C. That there is likely for multiple bone fractures is incorrect because while fractures are common in motor vehicle collisions, they are not the highest priority concern during initial assessment. Airway, breathing, circulation, and spinal protection take precedence.
D. That a spinal cord injury exists until proven otherwise is correct because in any client involved in significant trauma, especially a motor vehicle collision, spinal injury must be assumed. Maintaining spinal immobilization and preventing neck movement are critical to avoid further neurological damage. This principle aligns with trauma protocols emphasizing spinal precautions during primary survey assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While skin color can indicate oxygenation status, it does not confirm tube placement. Cyanosis may appear late, and relying solely on skin color can delay recognition of incorrect placement.
B. Respiratory rate shows ventilatory patternbut cannot reliably confirm endotracheal tube position. A patient may breathe or be ventilated even if the tube is in the esophagus or mainstem bronchus.
C. Checking cuff inflation ensures a seal to prevent air leaks, but it does not indicate proper tracheal placement. An inflated cuff in the esophaguswould not prevent misplacement.
D. Auscultation of bilateral breath soundsover the lungs is a primary bedside assessmentfor confirming proper endotracheal tube placement. Absence of sounds on one side may indicate mainstem intubation, while no breath sounds with epigastric gurgling suggests esophageal placement. This assessment is immediate, noninvasive, and criticalbefore confirming with a chest x-ray.
Correct Answer is D
Explanation
A. While notifying the provider may eventually be necessary, the immediate priority is to assess the client’s respiratory statusto determine the severity of hypoxia or respiratory distress.
B. The client is showing early signs of respiratory compromise(tachycardia, tachypnea, labored breathing, SpO2 91%) but is not yet in imminent life-threatening instability that would automatically trigger a rapid response.
C. Anxiety may be present, but it is secondary to the physiologic problem. Relaxation alone does not address hypoxemia or increased work of breathing.
D. The client demonstrates tachycardia, labored respirations, and low oxygen saturationdespite supplemental oxygen. The first nursing action is a focused assessment of airway, breathing, and oxygenationto identify causes such as obstruction, retained secretions, or hypoventilation. This assessment guides immediate interventions such as suctioning, oxygen adjustment, or positioning, which are critical before escalating care.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.