Question

A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?

Answer 1

Correct Answers:

Airway protection

Rationale :

🚑Airway protection is always the first priority in trauma care because it directly impacts oxygenation and survival.

🦴While preventing musculoskeletal disability is important, it is not a life-threatening concern in the immediate phase of trauma care.

❤️Cardiac arrhythmias may arise secondary to trauma, but airway compromise can lead to hypoxia and cardiac arrest if not addressed immediately.

🧠Although intracranial pressure is critical, maintaining a patent airway ensures oxygen delivery, which is essential before any neurological intervention.

📌Core Message

Airway protection is the top priority in multi-trauma cases because maintaining a patent airway is essential for oxygenation and life preservation, preceding any secondary concerns such as musculoskeletal or neurological issues.

Answer 2

Correct Answers:

Fluctuation of the fluid level within the water seal chamber

Rationale :

🌊Fluctuation (tidaling) in the water seal chamber indicates that the chest tube system is patent and responding to the client’s respiratory cycle.

❌Continuous bubbling suggests an air leak, which is abnormal in the water seal chamber.

🧪There should not be equal drainage in chambers, as only one chamber collects drainage; others function as part of the suction system.

🚫Absence of fluid in the tubing could indicate blockage or lack of drainage, which is not a sign of proper function.

📌Core Message

Proper chest tube function is confirmed by tidaling in the water seal chamber, showing air movement with respiration, which reflects system patency and effectiveness.

Answer 3

Correct Answers:

Airway obstruction

Rationale :

🔥Burns involving the face, neck, and chest increase the risk of airway edema, which can rapidly lead to airway obstruction and respiratory failure.

🛡️Although infection is a major complication in burn clients, it develops later, making it a secondary concern in the acute phase.

⚖️Fluid imbalance is expected with burns, but maintaining a patent airway takes precedence over fluid status.

💤Paralytic ileus can occur due to stress or immobility but is not immediately life-threatening compared to airway compromise.

📌Core Message

Burns to the upper body demand immediate airway monitoring because of the high risk of edema-induced obstruction, making it the top priority over systemic complications.

Answer 4

Correct Answers:

Monitor for manifestations of increased intracranial pressure.

Rationale :

📈Increased intracranial pressure (ICP) is the most serious complication after a subdural hematoma evacuation, and monitoring for its signs is essential to prevent herniation.

🌡️Fever or increased temperature may indicate infection but is not the first concern postoperatively.

🌬️Oximetry checks are routine but not as critical in the immediate detection of neurological decline.

💧CSF leaks are also important but do not take priority over monitoring for signs of life-threatening pressure elevation in the brain.

📌Core Message

Following a subdural hematoma evacuation, it is crucial to monitor for increased ICP as it is the most immediate and life-threatening complication.

Answer 5

Correct Answers:

Heart rate

Rationale :

📉A decreasing heart rate after fluid resuscitation indicates improved circulatory volume and perfusion, reflecting adequate fluid replacement.

💧Urine output should increase with proper fluid therapy, but a decrease could suggest ongoing hypovolemia.

⚖️Weight changes are delayed and not a reliable acute indicator of resuscitation success.

🩸Blood pressure can remain stable due to compensatory mechanisms, even if perfusion is inadequate.

📌Core Message

A decrease in heart rate is an early and sensitive sign of adequate fluid replacement, reflecting improved hemodynamic stability in burn clients.

Answer 6

Correct Answers:

Mannitol 25%

Rationale :

💧Mannitol is an osmotic diuretic used to reduce intracranial pressure by drawing fluid from the brain tissue into the bloodstream.

❌Dextran 70, albumin, and hydroxyethyl starch are volume expanders and do not reduce cerebral edema—in fact, they may worsen it.

🧠The goal is to decrease cerebral swelling and prevent brain herniation, which mannitol achieves effectively.

🔍Close monitoring of electrolytes and renal function is required during mannitol therapy due to the risk of imbalances.

📌Core Message

Mannitol is the drug of choice for reducing intracranial pressure due to its ability to draw fluid out of brain tissue, making it critical in managing traumatic brain injuries.

Answer 7

Correct Answers:

24

Rationale :

🧪To calculate the correct IV rate: (1,200 units/hr) ÷ (50 units/mL) = 24 mL/hr.

🧾Heparin concentration is 25,000 units in 500 mL, which equals 50 units/mL.

✅Accurate IV rate calculations are essential to ensure therapeutic anticoagulation and prevent complications like bleeding or clot formation.

📏Always use dimensional analysis or the ratio method to ensure proper medication delivery in continuous infusions.

📌Core Message

Accurate dosing of heparin infusions requires careful calculation based on concentration and dose per hour, and in this case, results in 24 mL/hr.

Answer 8

Correct Answers:

Location of the burn

Rationale :

🫁Burns on the face, neck, or chest compromise airway patency, which is life-threatening and therefore the most critical assessment factor.

📊While age and medical history influence healing and prognosis, they are not immediate threats.

🔥Burn cause helps predict severity and depth but does not surpass the urgency of burn location-related complications.

🤕Clients with burns in high-risk areas may need airway intervention, including intubation, making location a triage priority.

📌Core Message

Burn location is the top priority when assessing burn severity due to the potential for airway obstruction and critical complications associated with certain anatomical sites.

Answer 9

Correct Answers:

Mannitol 25%

Rationale :

🧠Cushing’s triad (bradycardia, hypertension, irregular respirations) is a late sign of increased intracranial pressure, requiring immediate osmotic therapy.

💧Mannitol works by reducing cerebral edema, improving perfusion and preventing brain herniation.

❌Dextran, albumin, and hydroxyethyl starch are inappropriate here as they do not decrease ICP and may worsen cerebral swelling.

👁️This intervention is aimed at preserving neurological function and preventing death from brainstem compression.

📌Core Message

Mannitol is the appropriate intervention for managing Cushing’s triad, as it effectively reduces intracranial pressure through osmotic diuresis, helping to prevent fatal brain herniation.

Answer 10

Correct Answers:

Checking the pupillary response to light

Rationale :

🔦Cranial nerve III (oculomotor) is responsible for pupil constriction and eye movement, so a light reaction test assesses its function.

🗣️Eliciting the gag reflex evaluates cranial nerves IX and X, not cranial nerve III.

📷Testing visual acuity checks cranial nerve II (optic), unrelated to oculomotor function.

😊Facial symmetry assesses cranial nerve VII (facial nerve), not involved in pupillary response.

📌Core Message

Cranial nerve III controls pupillary response, and testing it with a light reflex is the most accurate method of assessment.

1 :
A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?

2 :
The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?

3 :
A nurse in the emergency department is caring for a client who has extensive partial and full-thickness bums of the head, neck, and chest. While planning the clients care, the nurse should identify which of the following risks as the priority for assessment and intervention?

4 :
A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?

5 :
A nurse is monitoring a client who was admited with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

6 :
A nurse is caring for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Which of the following medications should the nurse plan to administer?

8 :
A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse’s priority when assessing the severity of the clients burns?

9 :
A nurse is caring for a client who is experiencing Cushing's triad following a subdural hematoma. Which of the following medications should the nurse plan to administer?

10 :
A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve Ill?

1 : A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?

2 : The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?

3 : A nurse in the emergency department is caring for a client who has extensive partial and full-thickness bums of the head, neck, and chest. While planning the clients care, the nurse should identify which of the following risks as the priority for assessment and intervention?

4 : A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?

5 : A nurse is monitoring a client who was admited with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

6 : A nurse is caring for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Which of the following medications should the nurse plan to administer?

8 : A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse’s priority when assessing the severity of the clients burns?

9 : A nurse is caring for a client who is experiencing Cushing's triad following a subdural hematoma. Which of the following medications should the nurse plan to administer?

10 : A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve Ill?

1 :
A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?

2 :
The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?

3 :
A nurse in the emergency department is caring for a client who has extensive partial and full-thickness bums of the head, neck, and chest. While planning the clients care, the nurse should identify which of the following risks as the priority for assessment and intervention?

4 :
A nurse is caring for a client who had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?

5 :
A nurse is monitoring a client who was admited with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

6 :
A nurse is caring for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Which of the following medications should the nurse plan to administer?

8 :
A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse’s priority when assessing the severity of the clients burns?

9 :
A nurse is caring for a client who is experiencing Cushing's triad following a subdural hematoma. Which of the following medications should the nurse plan to administer?

10 :
A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve Ill?