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

Answer and Explanation

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.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

A. Docusate sodium suppositories are commonly used to prevent constipation, which is important postoperatively, especially if the client is experiencing decreased bowel sounds and reports feeling bloated.

B. Ice application can help reduce swelling (edema) in the scrotal and penile area, which is noted in the client's assessment. This can help alleviate discomfort and promote healing.

C. Antispasmodic medications can help manage bladder spasms, which are common postoperatively due to the presence of an indwelling urinary catheter and continuous bladder irrigation.

D. While changing positions is important to prevent complications like pressure ulcers and promote comfort, specifically placing the client in a sitting position while in bed may not be necessary and could potentially interfere with postoperative recovery and comfort.

E. Teaching the client how to use a leg bag for urinary drainage is important, especially if the client will be discharged with a catheter. This education ensures the client can manage their urinary drainage system effectively.

A. A client who has a simple fracture of the femur, multiple scratches on both legs, and is crying hysterically B. A client who has severe head injuries, respiratory rate 6/min, and is unresponsive C. A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound site D. A female who is pregnant at 20 weeks of gestation, has multiple cuts and abrasions, and is walking around

Correct Answer is C

Explanation

A. While painful, a simple fracture and scratches do not pose an immediate threat to life compared to other injuries.
B. The client with severe head injuries and a low respiratory rate may seem like a priority, but if they are unresponsive and have a respiratory rate as low as 6/min, they may be beyond help.
C. A punctured chest with an audible hissing sound indicates a potential tension pneumothorax, a life-threatening condition that requires immediate intervention to prevent collapse of the lung and other potentially fatal complications.
D. A pregnant woman with cuts and abrasions should be evaluated promptly but is not as critical as clients with severe head injuries or tension pneumothorax.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has had an open radical prostatectomy. Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

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Correct Answer is C

Explanation

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