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 D
Explanation
Choice A rationale
Offering the client oral fluids is important for hydration, but it is not directly related to the care of an indwelling urinary catheter. The UAP can offer fluids to the client, but this action is not specifically tied to the turning of the client or the care of the urinary catheter.
Choice B rationale
Feeding the client a snack is a task that the UAP may perform, but it is not directly related to the care of an indwelling urinary catheter. The UAP can provide a snack to the client, but this action is not specifically tied to the turning of the client or the care of the urinary catheter.
Choice C rationale
Assessing breath sounds is within the scope of practice for a nurse, not a UAP. While it’s important to monitor a client’s respiratory status, this action is not directly related to the care of an indwelling urinary catheter.
Choice D rationale
Emptying the urinary drainage bag is an appropriate action for the UAP to take each time the client is turned. This action helps to prevent infection, maintain accurate intake and output records, and ensure the comfort and dignity of the client.
Correct Answer is B
Explanation
Choice A rationale
Using an electric heating pad when the pain is at its worst is not recommended for a client with gout. Heat can increase inflammation and exacerbate pain. Instead, applying a cold pack to the inflamed joint can help reduce inflammation and relieve pain.
Choice B rationale
Acetylsalicylic acid, also known as aspirin, can increase uric acid levels in the blood and exacerbate gout symptoms. Therefore, clients with gout should avoid taking medications containing acetylsalicylic acid.
Choice C rationale
Consuming high-protein foods can increase uric acid levels in the blood and trigger a gout attack. Clients with gout are usually advised to follow a low-purine diet, which involves limiting the intake of high-purine foods such as red meat and seafood.
Choice D rationale
Encouraging active range of motion to limit stiffness may not be appropriate for a client with an acute gout attack. During an attack, moving the affected joint can be extremely painful. Rest and immobilization of the affected joint are usually recommended during this time.
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