The nurse is assessing a patient with suspected traumatic cervical spine injury who just arrived to the emergency department. The nurse knows the priority actions for caring for this patient include all of the following. Place the actions in order of priority.
Complete a Glasgow Coma Scale assessment.
Apply pressure to any areas of uncontrolled bleeding.
Place an indwelling Foley catheter to monitor urine output.
The Correct Answer is B,A,C
Choice A reason:
Completing a Glasgow Coma Scale assessment is crucial in evaluating the neurological status of a patient with a suspected traumatic cervical spine injury. However, it should be done after ensuring that there is no uncontrolled bleeding.
Choice B reason:
Applying pressure to any areas of uncontrolled bleeding is the highest priority. Controlling bleeding is essential to prevent hypovolemic shock and maintain hemodynamic stability, which takes precedence over other assessments and interventions.
Choice C reason:
Placing an indwelling Foley catheter to monitor urine output is important for ongoing assessment of renal function and fluid balance. However, it is not the immediate priority compared to controlling bleeding and assessing neurological status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Arterial Blood Gas (ABG) analysis is the best method to determine the effectiveness of treatments in a client receiving mechanical ventilation. ABGs provide direct information about the patient's oxygenation, ventilation, and acid-base status, which are critical in managing acute respiratory failure.
Choice B reason:
While blood pressure is important for overall patient monitoring, it does not provide specific information about the effectiveness of ventilation and respiratory status. It is more related to hemodynamic stability.
Choice C reason:
Capillary refill can provide some information about peripheral perfusion but is not specific enough to assess the effectiveness of mechanical ventilation or respiratory treatments.
Choice D reason:
Heart rate is a vital sign that can indicate the patient's overall condition but does not specifically assess the effectiveness of ventilation or respiratory treatments. It should be considered along with other more specific respiratory assessments.
Correct Answer is C
Explanation
Choice A reason:
Lower levels of arterial carbon dioxide do not directly facilitate brain oxygenation. While maintaining appropriate CO2 levels is important for overall respiratory function, the primary reason for targeting a specific PaCO2 range in traumatic brain injury is related to intracranial pressure control.
Choice B reason:
Although carbon dioxide is indeed a waste product that must be eliminated from the body, this statement does not explain why specific PaCO2 levels are targeted in the context of traumatic brain injury. The primary concern is the impact of CO2 on intracranial pressure.
Choice C reason:
Carbon dioxide is a potent vasodilator, and elevated levels can lead to increased intracranial pressure (ICP). By maintaining PaCO2 within a range of 35-38 mmHg, the healthcare provider aims to prevent hypercapnia and the resulting vasodilation, which can exacerbate intracranial hypertension in patients with traumatic brain injury.
Choice D reason:
Lower levels of arterial carbon dioxide are not specifically essential for gas exchange. The primary concern with PaCO2 management in traumatic brain injury is controlling intracranial pressure, rather than optimizing gas exchange alone.
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