The nurse is caring for a client who was admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has respirations of 22/min, and a bleeding laceration to the forehead. Which of the following is the priority nursing action at this time?
Establish IV access and start fluid replacement.
Insert nasogastric tube.
Keep neck stabilized.
Monitor pulse and blood pressure frequently.
The Correct Answer is C
Choice A Reason:
Establishing IV access and starting fluid replacement is important for maintaining hemodynamic stability, especially if there is significant blood loss. However, it is not the immediate priority in this scenario. Ensuring the neck is stabilized takes precedence to prevent potential spinal cord injury.
Choice B Reason:
Inserting a nasogastric tube is not a priority in the acute management of a trauma patient with a head injury. This procedure can be deferred until the patient's airway and cervical spine are secured and other life-threatening conditions are addressed.
Choice C Reason:
Keeping the neck stabilized is the priority action. In a trauma patient with a head injury, there is a high risk of cervical spine injury. Stabilizing the neck prevents further damage to the spinal cord, which could result in paralysis or other severe complications.
Choice D Reason:
Monitoring pulse and blood pressure frequently is essential for assessing the patient's hemodynamic status. However, it is not the immediate priority over stabilizing the cervical spine. Once the neck is stabilized, continuous monitoring of vital signs should follow.
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Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Pneumonia is an infection of the lungs, not the ear. It primarily affects the alveoli, causing symptoms like cough, fever, and difficulty breathing. While respiratory infections can sometimes lead to ear infections, pneumonia itself does not directly infect the ear.
Choice B Reason:
Endocarditis is an infection of the inner lining of the heart chambers and valves. It is typically caused by bacteria entering the bloodstream and does not affect the ear. Symptoms include fever, heart murmurs, and fatigue.
Choice C Reason:
Myocarditis is an inflammation of the heart muscle, usually caused by viral infections. It affects the heart's ability to pump blood and does not involve the ear. Symptoms can include chest pain, fatigue, and shortness of breath.
Correct Answer is D
Explanation
Choice A Reason:
Monitoring the client's respiratory status and oxygen saturation is important but not the primary purpose of a hemodynamic monitoring system. Hemodynamic monitoring focuses on the cardiovascular system, including parameters like cardiac output, stroke volume, and systemic vascular resistance.
Choice B Reason:
Evaluating the client's renal function and electrolyte balance is crucial in overall patient care but is not the main focus of hemodynamic monitoring. Hemodynamic monitoring systems are designed to assess cardiovascular function rather than renal function.
Choice C Reason:
Monitoring the client's neurological status and intracranial pressure is essential in certain clinical situations, such as traumatic brain injury. However, this is not the primary purpose of hemodynamic monitoring, which is centered on cardiovascular assessment.
Choice D Reason:
The primary purpose of a hemodynamic monitoring system is to measure and assess the client's cardiovascular status and function. This includes monitoring parameters such as blood pressure, cardiac output, and tissue perfusion to ensure adequate organ perfusion and guide treatment decisions.
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