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, A, D, C
B. The first priority in a primary survey is to open and maintain the airway; in a trauma client, this is done with a jaw-thrust maneuver to protect the cervical spine. E. After the airway is established, the nurse should assess breathing and determine the effectiveness of ventilatory efforts. A. Once airway and breathing are stabilized, circulation is addressed by establishing IV access for fluid or blood administration. D. Disability is assessed next using tools such as the Glasgow Coma Scale to evaluate neurologic status. C. Exposure is the final step; the nurse removes clothing to perform a thorough assessment while preventing hypothermia.
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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. "Engage in a vigorous exercise program." This statement may not be suitable for a client with multiple sclerosis experiencing symptoms such as diplopia, dysmetria, and sensory changes. While exercise is beneficial for managing MS symptoms, it should be tailored to the individual's abilities and symptoms.
B. "Plan to relax in a hot tub spa each day." Hot tubs can exacerbate symptoms of multiple sclerosis, particularly heat sensitivity. Therefore, this statement is not appropriate for this client.
C. "Implement a schedule to include periods of rest." Fatigue is a common symptom of multiple sclerosis, and incorporating regular periods of rest into the daily schedule can help manage fatigue and conserve energy.
D. "Wear an eye patch on the right eye at all times." While wearing an eye patch may help alleviate diplopia (double vision), it is not typically recommended for continuous use and should be used under the guidance of an ophthalmologist or healthcare provider.
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