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 :

🔹 The primary priority in trauma care is ensuring a patent airway—this aligns with the ABC approach (Airway, Breathing, Circulation), which is foundational in emergency and trauma nursing.

🔹 Airway compromise can occur rapidly due to facial trauma, cervical spine injury, blood, or secretions.

🔹 Without a secure airway, oxygenation and ventilation are impossible, making all other interventions secondary.

🔹 Even in multi-system trauma, airway management precedes cardiac, musculoskeletal, or neurological concerns.

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Answer 2

Correct Answers:

Fluctuation of the fluid level within the water seal chamber

Rationale :

✅ Tidaling, or fluctuation of fluid in the water seal chamber, reflects the client’s inspiratory and expiratory pressure changes, which confirms a patent pleural connection.

✅ When functioning properly, the water will rise during inspiration and fall during expiration — this is a normal and expected finding.

✅ The absence of tidaling may indicate obstruction or lung re-expansion, while continuous bubbling in the water seal (not suction chamber) indicates an air leak.

✅ Fluctuation reassures the nurse that the system is intact and draining intrapleural air or fluid effectively.

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Answer 3

Correct Answers:

Airway obstruction

Rationale :

➤ Facial, neck, and chest burns pose a severe threat to the airway due to rapid edema formation, inhalation injury, and thermal damage to the upper airway.

➤ These injuries can cause laryngeal edema, mucosal blistering, or obstruction — even when the airway initially appears clear.

➤ Early airway management (e.g., prophylactic intubation) is crucial within the first few hours, especially when voice hoarseness, stridor, or soot is present.

➤ Infection, ileus, and fluid shifts are concerns but do not override the immediacy of airway compromise in this region of injury.

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Answer 4

Correct Answers:

Check the oximeter.

Rationale :

🔸 After brain surgery, the most immediate concern is oxygenation, as brain tissue is highly sensitive to even brief periods of hypoxia.

🔸 Monitoring SpO₂ via pulse oximeter ensures adequate oxygen delivery and alerts the nurse to early signs of respiratory compromise or aspiration risk.

🔸 While monitoring for CSF leaks and increased ICP are important, oxygen delivery takes priority immediately post-op to prevent secondary brain injury.

🔸 Early hypoxia may lead to re-elevation of ICP and poor neurological outcomes if not rapidly addressed.

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Answer 5

Correct Answers:

Urine output

Rationale :

🔹 In burn management, urine output is the most reliable and immediate indicator of adequate fluid replacement during resuscitation.

🔹 It reflects renal perfusion, which is directly linked to circulating volume and tissue perfusion.

🔹 The target output is typically 30–50 mL/hr in adults, or 0.5–1 mL/kg/hr, depending on the severity of the burn.

🔹 While heart rate, weight, and BP provide supportive data, they are less sensitive than urine output for evaluating effective resuscitation during the acute phase.

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Answer 6

Correct Answers:

Mannitol 25%

Rationale :

✅ Mannitol is an osmotic diuretic used to treat increased ICP by drawing water out of edematous brain tissue and into the bloodstream.

✅ This reduces cerebral edema, lowers ICP, and helps preserve cerebral perfusion pressure (CPP).

✅ It works quickly and is the first-line agent for reducing pressure after traumatic brain injury or cerebral hemorrhage.

✅ Mannitol requires close monitoring of serum osmolality and renal function to avoid fluid overload or electrolyte imbalance.

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Answer 7

Correct Answers:

24

Rationale :

✍️Use the formula:

✳️mL/hr = (Prescribed dose ÷ Concentration per mL)

↪ Prescribed dose: 1,200 units/hr

↪ Available concentration: 25,000 units in 500 mL

→ So, 1 mL = 50 units (25,000 ÷ 500)

👉 1,200 ÷ 50

👍 = 24 mL/hr

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Answer 8

Correct Answers:

Location of the bum

Rationale :

🔸 The location of the burn is the top priority in determining burn severity, especially when it involves high-risk areas like the face, neck, chest, hands, perineum, or joints.

🔸 Burns in these areas can affect airway function, mobility, and risk of infection.

🔸 For example, facial burns raise concern for inhalation injury, while circumferential chest burns can impair breathing.

🔸 While cause, age, and history influence treatment, the immediate location dictates urgency and intervention strategy.

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Answer 9

Correct Answers:

Mannitol 25%

Rationale :

🔹 Cushing’s triad — hypertension with widening pulse pressure, bradycardia, and irregular respirations — is a late sign of increased ICP.

🔹 Administering Mannitol 25% helps rapidly reduce ICP and prevent brain herniation by decreasing cerebral edema.

🔹 It draws excess fluid from brain tissues into the vascular system, where it can be excreted via the kidneys.

🔹 This is a life-saving intervention that must be initiated promptly when these neurological signs are detected.

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Answer 10

Correct Answers:

Checking the pupillary response to light

Rationale :

✅ Cranial nerve III (oculomotor) controls pupil constriction and eyelid elevation, making pupillary reaction to light the most appropriate assessment.

✅ The nurse shines a light in each eye and observes for direct and consensual constriction, which confirms intact function.

✅ It also innervates some extraocular muscles, contributing to eye movement, but the most specific and direct assessment is the pupillary light reflex.

✅ Early detection of CN III dysfunction is crucial in identifying increased ICP or brain herniation.

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RN ATI Custom Nurs 235 Summer~2023(Final)

No.

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 client’s 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?

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RN ATI Custom Nurs 235 Summer~2023(Final)

No.

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 client’s 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 client’s 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?