An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first?
a. Assess level of consciousness.
b. Obtain vital signs.
c. Administer oxygen therapy.
d. Evaluate respiratory status.
ANS: D
The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation. The other assessments should be performed after airway and breathing are assessed.
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