Author Question: A patient with a head injury after a motorcycle crash arrives in the emergency department (ED) ... (Read 112 times)

charchew · **on:** Jun 25, 2018

A patient with a head injury after a motorcycle crash arrives in the emergency department (ED) complaining of shortness of breath and severe eye pain. Which action will the nurse take first?

a. Administer the ordered analgesic.
b. Check the patient's oxygen saturation.
c. Examine the eye for evidence of trauma.
d. Assess each of the cranial nerve functions.

Question 2

The charge nurse observes a newly hired nurse performing all the following interventions for a patient who has just undergone right cataract removal and an intraocular lens implant. Which one requires that the charge nurse intervene?

a. The nurse leaves the eye shield in place.
b. The nurse encourages the patient to cough.
c. The nurse elevates the patient's head to 45 degrees.
d. The nurse applies corticosteroid drops to the right eye.

JYan · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: B
The priority action for a patient after a head injury is to assess and maintain airway and breathing. Because the patient is complaining of shortness of breath, it is essential that the nurse assess the oxygen saturation. The other actions are also appropriate but are not the first action the nurse will take.

Answer to Question 2

ANS: B
Because coughing will increase intraocular pressure, patients are generally taught to avoid coughing during the acute postoperative time. The other actions are appropriate for a patient after having this surgery.