During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next?
Examine the patient for any external bleeding.
Check the patient's level of consciousness.
Palpate extremities for bilateral pulses.
Observe the patient's respiratory effort
The Correct Answer is D
A. While external bleeding is important to assess and manage, it is not the next immediate action after confirming an unobstructed airway.
B. Checking the patient's level of consciousness should be done after assessing the respiratory effort.
C. Palpating extremities for bilateral pulses is part of assessing circulation, which typically follows the assessment of consciousness.
D. After ensuring the patient has an unobstructed airway, the next step in the primary assessment is to observe the patient's respiratory effort. This is crucial as it provides immediate information about the adequacy of the patient's breathing and the need for supplemental oxygen or other interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This statement is incorrect because tacrolimus (an immunosuppressant) is typically required long-term to prevent organ rejection after a kidney transplant. Stopping it prematurely can lead to rejection.
B. This statement is correct because immunosuppressant drugs used after a kidney transplant often target different pathways to prevent rejection.
C. This statement is correct because acute rejection episodes may necessitate adjustments or additions to the immunosuppressive regimen.
D. This statement is correct because immunosuppressive medications increase the risk of certain cancers, so close monitoring is essential.
Correct Answer is ["A","C","D"]
Explanation
A. In January, WBC count was 5,500/mm3. In February, it decreased to 4,500/mm3. A decrease in WBC count indicates an improvement in the client's condition, suggesting a potential reduction in chemotherapy-related immunosuppression.
B. In January, platelet count was 150,000/mm3. In February, it decreased slightly to 140,000/mm3. The slight decrease in platelet count may not necessarily indicate improvement but is relatively stable.
C. In January, the client reported bleeding episodes from mouth ulcers. In February, the client reports no bleeding episodes. The absence of bleeding episodes indicates improvement in oral mucosal health and potential effectiveness of interventions.
D. In January, the oral mucosa was inflamed. In February, there is noted improvement with less inflammation. Improved oral health with reduced inflammation indicates a positive response to interventions and potentially better oral hygiene practices.
E. The client experienced weight loss of 1.5 kg (3.3 lb) from January to February. Weight loss may indicate ongoing challenges with nutrition despite efforts to increase food intake and manage symptoms.
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