Difficulty: Medium
Average Score: 69%
Simulated
Spinal precautions are ordered for the client who sustained a neck injury during an MVA. The client has yet to be cleared that there is no cervical fracture. Which action is the nurseÔÇÖs priority when receiving the client in the ED?
Correct answer
C
Rationale
The nurse should determine the neurological status using the GCS, but this is not the priority. The nurse should assess sensation status at intervals to determine neurological injury progression, but this is not the priority. Maintaining the correct placement of the cervical collar will keep the clientÔÇÖs head and neck in a neutral position and prevent further injury if a spinal fracture or SCI is present. Because ensuring that the cervical collar is correctly placed will prevent further injury, it is priority. Applying antiembolism hose is an intervention to prevent thromboembolic complications, but this is not the priority.