During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?

Send blood to the lab for a complete blood count.

Finish the airway, breathing, circulation, disability survey.

Assess further for a cause of the decreased circulation,

Start normal saline fluid infusion with a large bore IV line.

Answer and Explanation

The Correct Answer is C

A. Sending blood to the lab for a complete blood count can wait until after immediate stabilization measures are initiated.
B. Finishing the primary survey is important, but the absent pulses and swollen leg suggest a critical vascular issue that needs immediate attention.
C. Assessing further for the cause of decreased circulation is the next step to determine if immediate intervention such as surgical consultation or revascularization is needed.
D. Starting normal saline infusion may be necessary later, but determining the cause of decreased circulation takes priority to prevent potential limb loss.

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Correct Answer is B

Explanation

A. Preparing a 60-mL syringe with saline may be necessary for gastric lavage but is not the first action.
B. For an unconscious patient who has ingested a significant quantity of lorazepam, securing the airway is the most critical first step to prevent aspiration and ensure the patient can breathe. Therefore, the nurse should assist with intubation of the patient.
C. The initial step is to ensure that the client’s airway is secured through intubation before administration of activated charcoal.
D. Inserting a large-bore orogastric tube may be necessary for gastric lavage but typically follows administration of activated charcoal.

A. Start oxygen using a non-rebreather mask, B. Have the patient drink large amounts of water. C. Give N-acetylcysteine. D. Discuss the use of chelation therapy.

Correct Answer is C

Explanation

A. Oxygen administration is not indicated for acetaminophen overdose unless respiratory distress is present.
B. Drinking water does not address acetaminophen overdose and its potential liver toxicity.
C. N-acetylcysteine is the antidote for acetaminophen overdose and should be administered to prevent liver damage.
D. Chelation therapy is not used in the treatment of acetaminophen overdose.

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During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Gastric lavage and administration of activated charcoal are prescribed for an unconscious patient who has been admitted to the emergency department (ED) after ingesting 30 lorazepam (Ativan) tablets. Which prescribed action should the nurse plan to do first?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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