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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Confusion: While confusion may occur in some neurological conditions, it is not directly associated with a positive Romberg test result.
B. Aphasia: Aphasia refers to difficulty with language and communication and is typically associated with brain injury or stroke, not with a positive Romberg test result.
C. Pain: Pain is not directly assessed by the Romberg test. However, a positive Romberg test result may indicate sensory ataxia, which can contribute to difficulty with proprioception and coordination, potentially leading to increased risk of injury and pain.
D. Falls: A positive Romberg test result indicates impaired proprioception and balance,
increasing the risk of falls, especially in older adults or individuals with neurological conditions. This is the expected problem associated with a positive Romberg test result.
Correct Answer is B, E, D, A, C
Explanation
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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