A patient with a head injury after a motorcycle crash arrives in the emergency department (ED) complaining of shortness of breath and severe eye pain. Which action will the nurse take first?
a. Administer the ordered analgesic.
b. Check the patient's oxygen saturation.
c. Examine the eye for evidence of trauma.
d. Assess each of the cranial nerve functions.
ANS: B
The priority action for a patient after a head injury is to assess and maintain airway and breathing. Because the patient is complaining of shortness of breath, it is essential that the nurse assess the oxygen saturation. The other actions are also appropriate but are not the first action the nurse will take.
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