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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Blood pressure itself does not directly affect stroke volume. However, it can influence afterload, which in turn affects stroke volume. Blood pressure is the force exerted by circulating blood on the walls of blood vessels, and while it is related to cardiac function, it is not a direct determinant of stroke volume.
Choice B Reason:
Preload directly affects stroke volume. Preload refers to the degree of stretch of the cardiac muscle fibers at the end of diastole, just before contraction. It is influenced by the volume of blood returning to the heart (venous return). According to the Frank-Starling law, an increase in preload leads to an increase in stroke volume due to the enhanced force of contraction.
Choice C Reason:
Afterload also directly affects stroke volume. Afterload is the resistance the ventricles must overcome to eject blood during systole. It is influenced by factors such as arterial blood pressure and vascular resistance. An increase in afterload can decrease stroke volume because the heart has to work harder to pump blood against the higher resistance.
Choice D Reason:
Heart rate does not directly affect stroke volume. Instead, heart rate and stroke volume together determine cardiac output (CO = HR × SV). While heart rate can influence the overall amount of blood pumped by the heart per minute, it does not directly change the volume of blood ejected with each beat.
Correct Answer is ["7.2"]
Explanation
Step-by-Step Calculation:
Step 1: Convert the client's weight from pounds to kilograms.
176 lbs ÷ 2.2 = 80 kg
Result = 80 kg
Step 2: Calculate the total dose of dopamine in mcg/min.
3 mcg/kg/min × 80 kg = 240 mcg/min
Result = 240 mcg/min
Step 3: Convert the total dose from mcg/min to mg/min.
240 mcg/min ÷ 1000 = 0.24 mg/min
Result = 0.24 mg/min
Step 4: Determine the concentration of dopamine in mg/mL.
500 mg ÷ 250 mL = 2 mg/mL
Result = 2 mg/mL
Step 5: Calculate the infusion rate in mL/min.
0.24 mg/min ÷ 2 mg/mL = 0.12 mL/min
Result = 0.12 mL/min
Step 6: Convert the infusion rate to mL/hr.
0.12 mL/min × 60 min/hr = 7.2 mL/hr
Result = 7.2 mL/hr
Final Result:
The IV pump should be set to 7.2 mL/hr.
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