Difficulty: Medium
Average Score: 84%
Simulated
The nurse in the emergency department (ED) is assessing a client involved in a motor vehicle crash who sustained a penetrating abdominal trauma. The clientÔÇÖs vital signs are: T 97.5┬░F (36.4┬░C); P 108 bpm; RR 22; BP 98/64 mm Hg; pulse oximetry 94% on room air. Which of the following actions should the nurse take first?
Correct answer
D
Rationale
Reassessing vital signs (D) is the first action to confirm stability or deterioration in a client with penetrating abdominal trauma and tachycardia/hypotension, guiding further interventions. Surgery prep (A), NG tube (B), and bowel sounds (C) follow reassessment.