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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.

Answer and Explanation

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.

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Correct Answer is ["A","B","D"]

Explanation

A. This may indicate a pneumothorax, which is a potential complication of thoracentesis.
B. A heart rate of 110/min may indicate tachycardia, which can be a sign of hypoxia or other complications.
C. While oxygen saturation of 95% is within the normal range, it is slightly lower than expected for a patient with respiratory distress.
D. This may indicate air leakage into the subcutaneous tissue, which can be a sign of a pneumothorax or other complications.

A. Because they witnessed their parents using drugs or alcohol to cope B. To treat pain and ease anxiety C. To treat hallucinations and perform better at work D. To promote sleep and rest

Correct Answer is B

Explanation

A. While parental influence can play a role in substance use disorders, there is no information in the scenario to support this as a potential underlying reason for the client's opioid use.
B. Chronic pain, such as that caused by Crohn's disease and a gymnastics injury, can lead individuals to seek relief through opioid use. Additionally, opioids may be used to selfmedicate underlying anxiety.
C. There is no mention of hallucinations in the client's history, and using opioids to perform better at work is not a typical reason for opioid use disorder.
D. While opioids can induce drowsiness and promote sleep, this is not typically a primary reason for developing an opioid use disorder in individuals with chronic pain conditions.

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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.)

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immediate follow-up.)

Correct Answer is ["A","B","D"]

Explanation

Correct Answer is B

Explanation

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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.)