Ati nur211 mobility exam
Ati nur211 mobility exam ( 29 Questions)
The nurse is attending to a client who was brought to the emergency department after a head-on collision. The client is unresponsive, has respirations of 22/min, and a bleeding forehead laceration. What is the priority nursing action in this situation?
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.
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.
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.
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.
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.