Physiological Adaptation Q 32

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A male client is admitted to the emergency department following an accident. What are the first nursing actions of the nurse?

  

     A. Check respiration, circulation, neurological response

     B. Align the spine, check pupils, and check for hemorrhage

     C. Check respirations, stabilize the spine, and check the circulation

     D. Assess level of consciousness and circulation

    

    

Correct Answer: C. Check respirations, stabilize the spine, and check the circulation

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Checking the airway would be the priority, and a neck injury should be suspected. Airway patency and adequate respiratory effort are both essential for normal oxygenation and ventilation within the body so that normal physiological processes can proceed without metabolic derangement.

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Option A: These assessments should be made, but keeping the spine stable is also a priority since the patient has been in an accident.

Option B: The first priority is always to check the airway, then the rest of the assessments would follow. Patency is assessed through the presence/absence of obstructive symptoms or findings suggesting an airway that may become obstructed.

Option D: The level of consciousness and circulation can be assessed after securing a patent airway.

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