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.)
Determine effectiveness of ventilator efforts.
Remove clothing for a thorough assessment.
Open the airway using a jaw-thrust maneuver.
Perform a Glasgow Coma Scale assessment.
Control any external bleeding.
The Correct Answer is C,A,D,B,E
The correct order is C,A,D,B,E.
C. Open the airway using a jaw-thrust maneuver.
This is the first priority since maintaining a clear airway is critical for the client’s survival.
A. Determine effectiveness of ventilatory efforts.
After ensuring the airway is open, assess the client’s breathing and whether they are ventilating effectively.
D. Perform a Glasgow Coma Scale assessment.
This step evaluates the client’s neurological status to determine their level of consciousness and identify any brain injuries.
B. Remove clothing for a thorough assessment.
To expose the client for a comprehensive physical examination and assess any injuries.
E. Control any external bleeding.
As part of circulation management, identify and stop any significant bleeding to prevent shock. This step addresses the "C" in ABCDE.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A family history of urolithiasis is a risk factor for developing the condition. Genetic factors can influence the risk of developing kidney stones.
B. Diuretic use can increase the risk of kidney stone formation by increasing the concentration of certain substances in the urine that can lead to stone formation.
C. A body mass index (BMI) less than 25 is not typically considered a risk factor for urolithiasis. Obesity, however, can be a risk factor for certain types of kidney stones.
D. Hypocalcemia (low calcium levels) can increase the risk of certain types of kidney stones, particularly those composed of calcium oxalate or calcium phosphate. However, hypocalcemia is not a common risk factor for urolithiasis.
Correct Answer is B
Explanation
A. Aphasia, or difficulty with language comprehension and expression, is more commonly associated with left hemisphere strokes.
B. Inability to recognize family members is a possible manifestation of right hemisphere stroke, particularly if the stroke affects the right parietal lobe. This condition is called prosopagnosia.
C. Right hemiparesis, or weakness on the right side of the body, is a possible manifestation of left hemisphere stroke, not right hemisphere stroke.
D. Difficulty reading is more commonly associated with left hemisphere strokes, which affect language centers involved in reading.
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