A patient with a suspected spinal injury is found unconscious. Which of the following actions should be taken first?

Correct Answer: B

Rationale: When a patient with a suspected spinal injury is found unconscious, the priority action is to secure the airway without jeopardizing the cervical spine. A jaw thrust maneuver is the appropriate technique to open the airway in this situation because it allows for the maintenance of neutral alignment of the cervical spine while ensuring proper ventilation. Moving the patient to a flat surface or applying a cervical collar could potentially worsen the spinal injury if not done correctly, and checking for responsiveness should only be done after ensuring a patent airway. Therefore, the safest and most effective initial action is to perform a jaw thrust maneuver to establish a clear airway.

Correct Answer: D

Rationale: The most appropriate oxygen delivery device for a patient with chronic respiratory failure secondary to severe restrictive lung disease requiring continuous supplemental oxygen is a non-rebreather mask. A non-rebreather mask is designed to deliver high-flow oxygen and is typically used for short-term medical treatment in emergency situations or for critically ill patients. It is ideal for providing the highest concentration of oxygen available for inhalation, making it suitable for patients with severe hypoxemia.

Correct Answer: B

Rationale: Tilt back Claudia's head slightly would have been the correct action to prevent her from blinking during eye drop instillation. By tilting her head back, you create a more stable position for instilling the eye drops, reducing the likelihood of accidental contact with her eyelid. Additionally, tilting the head back slightly helps in making it easier for the drops to enter the eye and stay within the conjunctival sac, improving the efficacy of the medication.

Correct Answer: A

Rationale: X-ray is the most commonly used imaging modality to diagnose fractures of the long bones, such as the femur or tibia. X-rays are readily available, fast, cost-effective, and provide detailed images of the bone structures. Fractures appear as breaks or discontinuities in the bone on X-ray images, making it an excellent tool for diagnosing bone fractures. In many cases, X-rays are sufficient to confirm the presence, location, and type of fracture, allowing for appropriate treatment planning. Other imaging modalities like MRI and CT scans may be used for further evaluation in complex cases, but X-ray remains the initial and primary choice for diagnosing long bone fractures.

Correct Answer: B

Rationale: When a patient receiving palliative care for end-stage cancer experiences severe nausea and vomiting despite current antiemetic therapy, the palliative nurse should consider switching to a different antiemetic medication with a different mechanism of action. This approach is based on the concept of individual variability in response to medications, as well as the potential development of tolerance to a particular drug. Switching to a different antiemetic with a new mechanism of action can provide the patient with a fresh chance at better symptom control by targeting different receptors or pathways involved in nausea and vomiting. It is important to consult the healthcare team and consider the patient's overall condition and medication history before making any changes in the treatment plan.

Correct Answer: C

Rationale: Nitroglycerin sublingual tablets are meant to be dissolved under the tongue to allow for rapid absorption into the bloodstream. Placing the tablet under the tongue helps to bypass the first-pass metabolism in the liver, leading to a quicker onset of action and chest pain relief. Chewing, swallowing, or applying the tablet to the skin will result in decreased effectiveness or delayed onset of action. Therefore, it is important for the patient to be instructed to place the nitroglycerin tablet under the tongue and allow it to dissolve for optimal therapeutic benefit.

Correct Answer: A

Rationale: Acute Respiratory Distress Syndrome (ARDS) is a severe form of acute lung injury that is characterized by hypoxemia, bilateral pulmonary infiltrates, and noncardiogenic pulmonary edema. When managing a patient with ARDS in the ICU, the priority intervention is to provide adequate oxygenation and ventilation. Mechanical ventilation is often necessary to support gas exchange in these patients.

Correct Answer: A

Rationale: Nurse Nilda immediately responds to any cry from her pediatric patients to attend to her patients who cannot communicate verbally. Crying is one of the few ways infants and young children communicate their needs and discomforts. By responding promptly to their cries, Nurse Nilda can assess and address potential issues such as hunger, pain, discomfort, or other needs that the child may have. This enhances the quality of care provided and helps in comforting and soothing the child, ultimately promoting their well-being and building trust between the nurse and the patient.

Correct Answer: A

Rationale: Shoulder dystocia is an obstetric emergency where one of the baby's shoulders becomes impacted behind the mother's pubic bone after the head delivers. This can lead to compression of the umbilical cord and compromise fetal oxygenation. The most critical nursing intervention in managing shoulder dystocia is applying suprapubic pressure to dislodge the impacted shoulder and allow for delivery of the baby. By gently pushing downwards on the mother's abdomen just above the pubic bone, the shoulder can be released, and the baby can be delivered successfully. This intervention should be prioritized to prevent potential complications for both the mother and the baby. Episiotomy may be considered if necessary, but it is secondary to addressing the shoulder dystocia. Oropharyngeal airway insertion and administering magnesium sulfate are not indicated in the immediate management of shoulder dystocia.