The trauma unit nurse has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

Correct Answer: A

Rationale: The correct answer is A: Evaluate chest expansion. This is the priority action because it assesses the client's airway and breathing, which are critical for survival. Checking chest expansion helps to identify any potential respiratory compromise or underlying lung injuries. Assessing pupillary response (B) and capillary refill (C) are important, but they are secondary to ensuring adequate oxygenation. Checking the client's orientation to place and time (D) is important for neurological assessment but is not as critical as assessing airway and breathing in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Airway protection. The priority focus of care in a client with multiple system trauma is to ensure a patent airway to maintain oxygenation and ventilation. Without a clear airway, the client can rapidly deteriorate. Airway management takes precedence over other interventions to prevent hypoxia and respiratory failure. Decreasing intracranial pressure (B) and stabilizing cardiac arrhythmias (C) are important but secondary to ensuring adequate oxygenation. Preventing musculoskeletal disability (D) is not the immediate concern in this critical situation.

Correct Answer: A

Rationale: The correct answer is A because Cheyne-Stokes respirations are characterized by a pattern of breathing that ranges from very deep to very shallow with periods of apnea. This pattern reflects an abnormal breathing cycle that is often seen in end-of-life care or in patients with severe neurological problems. Choice B is incorrect because it describes a pattern of shallow to normal breaths alternating with periods of apnea, which is not characteristic of Cheyne-Stokes respirations. Choice C is incorrect as it describes rapid respirations that are unusually deep and regular, which is not consistent with the pattern of Cheyne-Stokes respirations. Choice D is also incorrect because it describes an inability to breathe without dyspnea unless sitting upright, which is not a characteristic of Cheyne-Stokes respirations.

Correct Answer: A

Rationale: The correct answer is A: Respiratory acidosis. Shallow respirations at 9/min indicate hypoventilation, leading to retention of CO2 and respiratory acidosis. This is because inadequate removal of CO2 results in an increase in carbonic acid concentration, leading to a decrease in blood pH. Respiratory alkalosis (B) is unlikely with shallow respirations. Metabolic acidosis (C) results from nonrespiratory factors. Metabolic alkalosis (D) is not related to respiratory rate.

Correct Answer: D

Rationale: The correct answer is D, placing the client in a prone position. This intervention optimizes oxygenation by improving ventilation-perfusion matching in ARDS. When the client is in a prone position, there is better distribution of ventilation to the dorsal lung regions, reducing the risk of ventilator-induced lung injury. Choice A is incorrect because low-flow oxygen may not be sufficient to meet the oxygen demands of a client with ARDS. Choice B is incorrect because excessive oral intake can lead to fluid overload in ARDS. Choice C is incorrect because high-protein and high-carbohydrate foods may be difficult for the client to tolerate and can contribute to increased carbon dioxide production.