# A nurse is caring for an unconscious 40-year-old client who was admitted following a motorcycle accident. Which nursing action should be the nurse's first priority?

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> subject: Adult Health

## 문제

A nurse is caring for an unconscious 40-year-old client who was admitted following a motorcycle accident. Which nursing action should be the nurse's first priority?

## 보기

1. Check for responsiveness using the Glasgow Coma Scale
2. Insert a nasogastric tube to prevent aspiration
3. Assess and maintain airway patency **✔ 정답**
4. Obtain vital signs and neurological assessment

**정답: 3**

## 해설

For unconscious clients, maintaining airway patency is the first priority according to ABC principles to prevent hypoxia and death. Other actions like GCS assessment, NG tube insertion, and vital signs are secondary.

## 심화 해설

Priority Setting in Trauma Nursing: The ABC Principle

When caring for an unconscious client following a motorcycle accident, the nurse must apply the ABC (Airway, Breathing, Circulation) priority-setting framework. This systematic approach, foundational to both prehospital and emergency department trauma care, dictates that interventions addressing immediate threats to life take precedence over detailed assessments or secondary interventions.

Why Airway Takes Precedence Over Neurological Assessment

In the unconscious trauma patient, loss of pharyngeal muscle tone and impaired protective reflexes create an immediate risk of airway obstruction. The tongue can fall posteriorly against the posterior pharyngeal wall, and the absence of a gag reflex means the patient cannot clear secretions, blood, or foreign material. Apnoea—the cessation of breathing—is identified in trauma literature as one of the most critical and potentially reversible contributors to early mortality, capable of causing hypoxic brain injury within minutes if not corrected [1].

Assessing airway patency and intervening to maintain it directly addresses this time-sensitive threat. Without a patent airway, oxygen delivery to all tissues, including the brain, ceases. This means that performing a neurological assessment using the Glasgow Coma Scale (option 1) or obtaining vital signs (option 4) before securing the airway would delay the most critical, life-saving intervention. The data gathered from those assessments would be clinically meaningless if the patient is not being oxygenated.

The Role of Aspiration Prevention and Evidence-Based Sequencing

Inserting a nasogastric tube (option 2) is an important intervention to decompress the stomach and reduce the risk of aspiration of gastric contents. However, the evidence from trauma quality improvement research demonstrates that adherence to a structured checklist—which prioritizes airway and breathing assessment immediately upon patient arrival—significantly reduces emergency treatment time and improves care efficiency . The checklist approach reinforces that airway patency must be established first; gastric decompression is a secondary step that follows, not precedes, the stabilization of the airway and breathing.

Furthermore, best-practice evidence for managing hypoxemia in perioperative and acute care settings emphasizes that the initial and continuous priority is a focused respiratory assessment, including immediate evaluation of airway patency, breathing pattern, and oxygen saturation . This evidence base consistently ranks airway security above all other nursing actions in the sequence of care.

Applying the Trauma Care Framework

Guideline syntheses for early trauma and burn injury care in resource-limited settings universally reinforce the Airway with cervical spine protection as the first step in the primary survey . The mechanism of injury—a motorcycle accident—carries a high risk for cervical spine injury, making the jaw-thrust maneuver the appropriate method for opening the airway while maintaining spinal immobilization. The nurse's first priority is therefore to visually inspect the oropharynx for obstruction, suction as needed, and perform a jaw-thrust to establish patency, ensuring that the fundamental requirement for oxygenation is met before proceeding to any other component of the trauma assessment. The systematic prioritization of airway intervention is not merely a procedural step but a direct response to the pathophysiology of rapid hypoxic injury in the apnoeic or obstructed trauma patient [1].

References (research sources)

- [1]Managing apnoea in trauma victims: the potential for dispatcher-assisted airway handling - a narrative review.Research articleImbriaco G, D'arrigo S, Limonti F, Rehn M, Cucino A. (2025) · DOI: 10.1186/s13049-025-01533-w

## 임상 시나리오

Airway First in Unconscious TraumaApplying the ABC Priority Framework
In an unconscious patient, loss of pharyngeal muscle tone can cause the tongue to obstruct the airway. The absence of a gag reflex increases aspiration risk. Immediate airway assessment and intervention is the priority to prevent hypoxic brain injury, which can occur within minutes.

CautionDo not delay securing the airway to perform a detailed neurological exam (e.g., Glasgow Coma Scale) or obtain full vital signs. Airway management always takes precedence in the initial trauma assessment.

## 핵심 개념

- **ABC Priority Framework** — A systematic approach in trauma care prioritizing Airway, Breathing, and Circulation to address immediate life threats.
- **Glasgow Coma Scale (GCS)** — A neurological scale used to assess a patient's level of consciousness; secondary to airway management in initial trauma assessment.
- **Airway Patency** — The state of the airway being open and unobstructed, allowing for effective ventilation and gas exchange.
- **Aspiration** — The inhalation of foreign material (e.g., gastric contents, blood) into the lungs, a risk in patients with impaired protective reflexes.
- **Apnoea** — The cessation of breathing, a critical contributor to early mortality in trauma that can lead to rapid hypoxic brain injury.

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