You have just admitted a patient to the ED following a fall from a first floor hotel balcony. The patient is 22 years old and smells of alcohol. The patient begins to vomit in the ED. Which of the following interventions is most appropriate?

Insert an oral airway to prevent aspiration and to protect the airway.

Offer the patient an emesis basin so that you can measure the amount of emesis.

Prepare to suction the oropharynx while maintaining cervical spine immobilization.

Send a specimen of the emesis to the laboratory for analysis of blood alcohol content.

Answer and Explanation

The Correct Answer is C

Rationale:
A. Inserting an oral airway is not the most appropriate intervention in this situation. In a trauma patient with a possible cervical spine injury, placing an oral airway without strict spinal precautions could worsen spinal damage. In addition, oral airways are generally reserved for patients who are unconscious and lack a gag reflex; this patient is actively vomiting and may still have protective airway reflexes.

B. Offering an emesis basin does not address the primary concern of airway protection. In a trauma patient with suspected intoxication and possible head injury, the risk of aspiration is high, and simply measuring emesis does not prevent airway compromise.

C. Preparing to suction the oropharynx while maintaining cervical spine immobilization is the most appropriate intervention. Vomiting poses an immediate risk of airway obstruction and aspiration. Because the patient experienced a traumatic fall, cervical spine injury must be assumed until ruled out. Suctioning clears vomitus from the airway while spinal precautions protect against further injury, addressing the highest priority in emergency care.

D. Sending emesis to the laboratory for blood alcohol analysis is not a priority during the acute phase of trauma management. Airway protection and spinal stabilization take precedence over diagnostic testing.

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Correct Answer is D

Explanation

Rationale:
A. Placing the patient in high-Fowler’s position is incorrect because while it can improve ventilation, the disappearance of wheezes with decreased or absent breath sounds may indicate progressive airway obstruction, which is life-threatening and requires immediate provider notification. Positioning alone will not prevent airway compromise.

B. Encouraging the patient to cough and auscultating again is incorrect because the patient may have airway edema from inhalation injury, and attempting to cough may not relieve obstruction or alert staff to impending respiratory failure. This delays urgent intervention.

C. Documenting the results and continuing to monitor is incorrect because absent or decreased breath sounds in a patient with inhalation injury is an emergency. Waiting could result in complete airway obstruction and respiratory arrest.

D. Notifying the health care provider is correct because the loss of previously audible wheezes and decreased lung sounds indicates worsening airway edema or obstruction, which requires immediate evaluation and possible airway intervention (e.g., intubation). Rapid assessment and provider notification are critical to prevent respiratory failure.

A. To prevent the formation of infarcts of emboli B. To limit stroke volume and cardiac output C. To prevent pulmonary and peripheral edema D. To maintain adequate mean arterial pressure

Correct Answer is D

Explanation

Rationale:
A. Preventing infarcts or emboli is not the primary purpose of vasoactive medications. While some anticoagulants may reduce clot formation, vasoactive drugs are focused on hemodynamic support, not clot prevention.

B. Limiting stroke volume and cardiac output is counterproductive in shock. Shock occurs due to inadequate tissue perfusion, and decreasing cardiac output would worsen hypoperfusion and organ dysfunction.

C. Preventing pulmonary and peripheral edema is a secondary concern. While careful fluid management and some medications can reduce edema, vasoactive agents do not primarily target fluid accumulation.

D. The primary goal of vasoactive medications (such as dopamine, norepinephrine, or phenylephrine) is to maintain adequate mean arterial pressure (MAP) to ensure perfusion of vital organs. In shock, blood pressure may fall due to hypovolemia, vasodilation, or cardiac dysfunction. Vasoactive drugs constrict blood vessels and/or increase cardiac output, supporting MAP and improving tissue oxygen delivery. Maintaining an adequate MAP (usually ≥65 mm Hg) is crucial to prevent organ ischemia and progression to multi-organ failure.

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You have just admitted a patient to the ED following a fall from a first floor hotel balcony. The patient is 22 years old and smells of alcohol. The patient begins to vomit in the ED. Which of the following interventions is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a patient in shock. The nurse knows that vasoactive medications are given in all forms of shock. What is the primary goal of this aspect of treatment?

Correct Answer is D

Explanation

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