22. A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)
Establish IV access.
Open the airway using a jaw-thrust maneuver.
Remove clothing for a thorough assessment.
Perform a Glasgow Coma Scale assessment..
Determine effectiveness of ventilator efforts.
The Correct Answer is B, E, D, A, C
B. The first action in a primary survey is to open the airway to ensure it is not obstructed, especially if the client is unconscious or has altered mental status.
E. Once the airway is secured, determining the effectiveness of ventilatory efforts is essential to ensure adequate oxygenation.
D. After airway and breathing are addressed, performing a Glasgow Coma Scale assessment helps determine the level of consciousness and neurological status.
A. Establishing IV access is crucial for fluid resuscitation and medication administration but is not the first step in a primary survey.
C. Finally, removing clothing is necessary for a thorough assessment, but it comes after the critical steps of airway, breathing, and circulation have been addressed.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Check the client's phenytoin (Dilantin) level: Checking the phenytoin level would not be relevant in this situation as the client's presentation suggests a possible stroke, not related to phenytoin therapy.
B. Get an order to decrease the rate of IV fluids: While managing fluid balance is important, there is insufficient information to warrant decreasing IV fluids at this time. It's essential to assess the client's overall condition and consult with the healthcare provider before making changes to IV fluid administration.
C. Ask the woman to describe how she's feeling: Assessing the client's symptoms and response to treatment is crucial for monitoring her condition and guiding further interventions, especially in
the context of a possible stroke.
D. Offer the client clear liquids to prevent dehydration: While maintaining hydration is
important, offering clear liquids would not address the potential stroke or irregular respirations. Assessment and intervention related to the client's neurological status and respiratory function take precedence.
Correct Answer is C
Explanation
A. Start a labetalol drip to keep BP less than 140/90 mm Hg: This order is appropriate because it aims to lower the patient's blood pressure to a target range recommended for acute ischemic stroke management.
B. Keep the head of the bed elevated at least 30 degrees: This intervention is part of stroke management to prevent aspiration and improve cerebral perfusion.
C. Begin tissue plasminogen activator (tPA) intravenously per protocol: The nurse should question this order because tissue plasminogen activator (tPA) is contraindicated in patients with stroke who have had symptoms for more than 3 hours or have unknown time of onset, as in this case where the patient has been aphasic for 3 hours. Administering tPA in this situation could increase the risk of bleeding complications without providing benefit.
D. Infuse normal saline intravenously at 75 mL/hr: This order is appropriate for maintaining hydration and intravascular volume in the acute care setting.
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