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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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale
While obtaining an analgesic prescription might help to alleviate the client’s joint pain, it is not the first intervention that should be implemented. The client’s vital signs indicate that they are in a state of shock, which is a medical emergency.

Choice B rationale
Infusing an intravenous fluid bolus is often the first step in treating shock. The client’s low blood pressure and high heart rate suggest that they may be experiencing hypovolemic shock, which can be caused by a severe fluid loss. Administering fluids can help to increase blood volume and improve blood pressure.

Choice C rationale
Administering a PRN oral antipyretic would not address the client’s immediate need. The client’s high temperature is a concern, but the low blood pressure and high heart rate are more immediate concerns.

Choice D rationale

Covering the client with a cooling blanket would address the client’s high temperature, but it would not address the more immediate concerns of low blood pressure and high heart rate.

Correct Answer is ["1.8"]

Explanation

The client weighs 132 pounds. To convert pounds to kilograms, divide the weight in pounds by

2.2. So, the client’s weight in kilograms is: Step 1: 132 pounds ÷ 2.2 = 60 kg The prescription for dantrolene is 1.5 mg/kg. To find out how many milligrams the client should receive, multiply the client’s weight in kilograms by the dosage in mg/kg: Step 2: 60 kg × 1.5 mg/kg = 90 mg The vial is reconstituted to yield a concentration of 50 mg/mL. To find out how many mL the nurse should administer, divide the total dosage in milligrams by the concentration in mg/mL: Step 3: 90 mg ÷ 50 mg/mL = 1.8 mL So, the nurse should administer 1.8 mL of dantrolene.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is ["1.8"]

Explanation

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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?