The Unconscious Client

A nurse is caring for an unconscious client who was admitted following a traumatic brain injury. Which nursing action should be the nurse's first priority?

1 Assess the client's airway patency and breathing pattern ✓ 정답
2 Check the client's pupillary response to light
3 Monitor the client's blood pressure and heart rate
4 Evaluate the client's level of consciousness using the Glasgow Coma Scale

해설

For an unconscious client with traumatic brain injury, maintaining airway patency is the first priority per ABC principles to prevent hypoxia and secondary brain injury. Other assessments are important but secondary to ensuring adequate oxygenation.

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Priority Setting in the Unconscious Client with Traumatic Brain Injury

The correct first action is to assess the client's airway patency and breathing pattern. This decision is firmly grounded in the foundational trauma care principles outlined in the Guidelines for Essential Trauma Care, which prioritize the sequential, systematic approach of the primary survey. For an unconscious client with a traumatic brain injury (TBI), the immediate threat to life is not the brain injury itself, but the secondary hypoxia and respiratory failure that can result from a compromised airway.

The primary survey follows the ABCDE (Airway, Breathing, Circulation, Disability, Exposure) algorithm, a universally accepted standard in trauma resuscitation ^[1]. The "A" (Airway) and "B" (Breathing) components always take precedence over "D" (Disability), which includes a neurological assessment. An unconscious client is at extreme risk for airway obstruction due to loss of pharyngeal muscle tone, allowing the tongue to fall back, or from the inability to clear secretions, blood, or vomitus. Concurrently, the respiratory drive may be depressed directly from the brain injury, leading to hypoventilation. The guidelines emphasize that establishing a secure airway and ensuring adequate ventilation and oxygenation are the most critical initial steps to prevent secondary brain injury from hypoxia and hypercapnia, which drastically worsen outcomes ^[1].

The other options represent components of the secondary survey or the "D" (Disability) portion of the primary survey, which are performed only after the airway and breathing have been stabilized. Checking pupillary response (Option 2) and evaluating the level of consciousness using the Glasgow Coma Scale (Option 4) are vital neurological assessments that help localize the injury and establish a baseline for monitoring deterioration, a concept echoed in the study on coma recovery . However, these assessments are clinically meaningless if the brain is not being perfused with oxygenated blood. Similarly, while monitoring blood pressure and heart rate (Option 3) is crucial for assessing the "C" (Circulation) component and preventing secondary injury from hypotension, it is secondary to the immediate life-saving intervention of securing the airway. The systematic approach dictates that the most life-threatening condition—in this case, potential airway compromise and respiratory failure—is addressed first ^[1].

References (research sources)

[1]
Guidelines for Essential Trauma Care: Second Edition (2026).GuidelineMock C, Hardcastle TC, Gaarder C, Gupta A, Gyedu A, Joshipura M, Steyn E, Essential Trauma Care revision author group. (2026) · DOI: 10.1002/wjs.70321

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A nurse is caring for an unconscious client who was admitted following a traumatic brain injury. Which nursing action should be the nurse's first priority?

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