A client is brought to the emergency department after a car crash. The client has a large piece of glass in the left eye. What action by the nurse takes priority?
a. Administer a tetanus booster shot.
b. Ensure the client has a patent airway.
c. Prepare to irrigate the client's eye.
d. Turn the client on the unaffected side.
ANS: B
Airway always comes first. After ensuring a patent airway and providing cervical spine precautions (do not turn the client to the side), the nurse provides other care that may include administering a tetanus shot. The client's eye may or may not be irrigated.
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