A school nurse is treating a school-age client who has fallen down a flight of stairs. The client is breathing but unconsciousness. After calling the ambulance, the nurse should:
1. Protect the client's neck and head from any movement.
2. Place the client on the side to prevent aspiration.
3. Open the airway using the head tilt maneuver.
4. Try to rouse the client by gently shaking the shoulders.
1. Protect the client's neck and head from any movement.
Rationale:
Guidelines for emergency care are avoiding flexing, extending, or rotating the neck; immobilization of the neck; securing the head; maintaining the client in the supine position; and transferring from the stretcher with backboard in place to the hospital bed. This client is unconscious, and the nurse must protect the neck from any (or any further) damage. If the client vomits, the nurse should utilize the log-roll technique to turn the client while keeping the head, neck, and spine in alignment. The client is breathing; however, if a change in respirations would occur, the airway should be opened using the jaw thrust maneuver. Rousing the client by shaking could cause damage to the spinal cord.
You might also like to view...
A patient with hypertrophic cardiomyopathy (HCM) has been admitted to the medical unit
During the nurse's admission interview, the patient states that she takes over-the-counter "water pills" on a regular basis. How should the nurse best respond to the fact that the patient has been taking diuretics? A) Encourage the patient to drink at least 2 liters of fluid daily. B) Increase the patient's oral sodium intake. C) Inform the care provider because diuretics are contraindicated. D) Ensure that the patient's fluid balance is monitored vigilantly.
The nurse is assessing the client and notes on physical exam that the client has an enlarged forehead and protruding jaw. The nurse suspects that the client is experiencing:
1. gigantism. 2. deficient ADH. 3. acromegaly. 4. hypopituitarism.
The nurse is assessing a newborn when the mother asks about the tiny white "bumps" on the forehead and nose. The nurse would respond to the mother with which of the following statements?
1. "Those are milia and they are very common.". 2. "That is lanugo and it is very common.". 3. "Those are Mongolian spots.". 4. "Those are salmon patches.".
A nurse performing an admission history on a patient learns that the patient is taking orlistat (Xenical), warfarin (Coumadin), and levothyroxine (Synthroid). What will the nurse do?
a. Contact the provider to discuss increasing the warfarin dose. b. Give the levothyroxine at least 4 hours before giving the orlistat. c. Suggest that the patient avoid fatty foods while taking these medications. d. Tell the patient to take the orlistat on an empty stomach.