The client is a 26-year-old female who fell from an apartment balcony. She was transported to the hospital via ambulance.
The client enters the emergency room on a stretcher and is met in the trauma bay by the nurse.
What two actions should the nurse take first during the primary survey?
Stabilize the cervical spine.
Check for a pulse.
Request an x-ray.
Assess the respiratory rate.
Examine the abdomen.
Ensure the airway is patent.
Correct Answer : A,F
Choice A rationale
Stabilizing the cervical spine is one of the first actions that should be taken during the primary survey of a trauma patient. This is to prevent any potential injury to the spinal cord, which could result in permanent paralysis.
Choice B rationale
Checking for a pulse is an important part of the primary survey, but it is not one of the first actions that should be taken. The first priority is to ensure that the airway is patent and the cervical spine is stabilized.
Choice C rationale
Requesting an x-ray is not one of the first actions that should be taken during the primary survey. The first priority is to assess the client’s airway, breathing, and circulation, and to stabilize the cervical spine.
Choice D rationale
Assessing the respiratory rate is an important part of the primary survey, but it is not one of the first actions that should be taken. The first priority is to ensure that the airway is patent and the cervical spine is stabilized.
Choice E rationale
Examining the abdomen is an important part of the secondary survey, which is conducted after the primary survey. The first priority during the primary survey is to assess the client’s airway, breathing, and circulation, and to stabilize the cervical spine.
Choice F rationale
Ensuring that the airway is patent is one of the first actions that should be taken during the primary survey. This is to ensure that the client is able to breathe effectively and receive adequate oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Anticipating and monitoring for hypothermia is the most crucial nursing intervention to include in the care plan for a patient who is 12 hours post-thyroidectomy. The thyroid gland plays a significant role in regulating the body’s metabolism, including temperature regulation. After a thyroidectomy, the body may struggle to regulate temperature, leading to hypothermia. The nurse should monitor the patient’s temperature regularly and provide warming measures as needed.
Choice B rationale
Preparing to administer radioactive iodine treatments is not the most crucial intervention at this time. Radioactive iodine is typically used as a treatment for hyperthyroidism or thyroid cancer, not as an immediate post-operative intervention.
Choice C rationale
Resuming antithyroid drug therapy is not the most crucial intervention at this time. Antithyroid drugs are used to treat hyperthyroidism, and their use would need to be evaluated based on the reason for the thyroidectomy and the patient’s post-operative thyroid hormone levels.
Choice D rationale
Maintaining a semi-Fowler position can be beneficial for comfort and respiratory function post-operatively, but it is not the most crucial intervention. The nurse should assist the patient to a comfortable position and encourage regular deep breathing and coughing exercises to prevent respiratory complications.
Correct Answer is D
Explanation
The correct answer is Choice D.
Brief Introduction This scenario requires applying knowledge of chest tube dynamics and respiratory physiology during patient positioning. Sudden dyspnea in a patient with a hemopneumothorax indicates a potential obstruction in the drainage system, necessitating immediate troubleshooting of the tubing to ensure lung re-expansion and prevent tension pneumothorax or fluid accumulation.
Choice A rationale: Reinforcing the connection with tape is a preventive measure to maintain system integrity. However, it does not address the immediate cause of sudden acute respiratory distress following a position change, which is more likely related to a mechanical obstruction in the tubing rather than a connection failure.
Choice B rationale: Clamping a chest tube is generally contraindicated as it can rapidly lead to a tension pneumothorax by preventing the escape of air and fluid from the pleural space. This action would likely worsen the patient's anxiety and shortness of breath by increasing intrapleural pressure.
Choice C rationale: An occlusive dressing is only applied if the chest tube is accidentally dislodged from the insertion site. Since the scenario implies the tube is still in place but the patient became symptomatic during a turn, applying a dressing over an intact tube is an incorrect intervention.
Choice D rationale: Turning a patient can cause the chest tubing to kink or create dependent loops that trap fluid. This obstruction prevents the drainage of air and blood, leading to sudden respiratory distress. Ensuring the tubing is patent and straight is the immediate priority to restore proper pleural suction.
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