Safe, Effective Care Environment
69. What should be the first nursing actions for a client admitted to an emergency department following an accident?
Safe, Effective Care Environment
69. What should be the first nursing actions for a client admitted to an emergency department following an accident?
. Check respirations, circulation, neurological response.
. Align the spine, check pupils, check for hemorrhage.
. Check respirations, stabilize spine, check circulation.
. Assess level of consciousness, circulation.
Test-Taking Tip
When appropriate for the injury, remember "ABCs" as priorities.
Content Area: Adult Health, Trauma; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Safe Effective Care Environment/Management of Care/Establishing Priorities
Safe, Effective Care Environment
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Answer 1 is incorrect because preventing damage, if the neck was broken, would be a priority over neurological checks. Answer 2 is incorrect because checking the airway is not included. Answer 3 is correct because checking the airway would be a priority, and a neck injury should be suspected. Answer 4 is incorrect because checking the airway and stabilizing the neck and spine are not included.