An emergency department nurse is sent to the scene of a massive motor vehicle collision. A client there reports neck pain. Which actions should the nurse perform at this time? Select all that apply.

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11ecbb05_cb07_5b0d_b433_e330978d6c13_MD0009_00 The initial priorities for a client with a suspected cervical spine injury are to ensure a patent airway and immobilize the spine to prevent further injury. This includes applying a rigid hard collar, placing the client on a firm surface (eg, a backboard), and moving the client as a unit (logrolling) if required (Options A, D, and E). A soft foam cervical collar does not provide immobilization. Further stabilization is achieved by taping down the client's head and using straps to immobilize the arms, especially if the client is not cooperating. After immobilizing the client, the nurse should obtain a baseline set of vital signs to monitor for neurogenic shock (eg, hypotension, bradycardia, poikilothermia [ie, inability to regulate body temperature]), a potential complication of spinal cord injury. The nurse should also assess the client's respiratory rate, pattern, and effort. Presence of abdominal breathing or increased work of breathing may indicate impending loss of airway and require prompt rapid-sequence intubation (Option C). (Option B) Movement of the neck/upper extremities should be avoided until cervical spine injury is ruled out with imaging, which is done after the spine is immobilized with a hard collar. Educational objective: The priorities for a client with a suspected cervical spine injury are maintaining a patent airway and spinal immobilization. Interventions include application of a rigid hard collar, placing the client on a firm surface, logrolling the client during movement and transfers, and continued assessment of need for an advanced airway.

An Emergency Department Nurse Is Sent to the Scene of a Massive