Which of the following would the nurse understand is correct when implementing a primary assessment for clients suffering major trauma? The primary assessment:

includes the head-to-toe anterior and posterior assessment.

priorities are continuing and ongoing but treatment will be deferred if the clients unstables

is focused on airway maintenance and ventilation effectiveness.

focuses on the ABCDs of the client to identify life threatening problems

Answer and Explanation

The Correct Answer is D

A. includes the head-to-toe anterior and posterior assessment.
This describes a secondary assessment, not a primary one. The primary assessment focuses on the immediate life-threatening issues rather than a full head-to-toe examination.

B. priorities are continuing and ongoing but treatment will be deferred if the client is unstable.
In primary assessment, treatment should not be deferred in unstable clients. Immediate treatment and stabilization take priority.

C. is focused on airway maintenance and ventilation effectiveness.
As airway and ventilation are key aspects of the primary assessment (known as the "ABC" of trauma: Airway, Breathing, Circulation). However, it does not cover all of the primary assessment areas.

D. focuses on the ABCDs of the client to identify life-threatening problems.
The primary assessment is focused on identifying life-threatening problems using the ABCDs (Airway, Breathing, Circulation, Disability).

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Correct Answer is D

Explanation

A. Elevate the extremity and apply an ice pack to the injured area

Elevating the extremity can help reduce swelling, but applying ice is not recommended for chemical burns as it can cause further tissue damage.

B. Contact poison control to determine the best neutralizing agent

While contacting poison control is important, it should not be the immediate first action in an emergency setting.

C. Apply a sterile dressing, wrapping the fingers separately

This is important for protecting the wound, but it is not the immediate first action needed for chemical burns.

D. Irrigate the affected area with room temperature water

Immediate irrigation with room temperature water helps to remove the chemical from the skin and dilute its effect, which is the first critical step in managing a chemical burn.

A. Color of conjunctiva B. Deep tendon reflexes C. IV Insertion site D. Blood pressure and heart rate E. Hourly urine output

Correct Answer is ["C","D","E"]

Explanation

A. Color of conjunctiva
While assessing for signs of perfusion is important, conjunctival color is not a primary assessment for norepinephrine administration. Perfusion is better assessed through blood pressure, heart rate, capillary refill, and urine output.

B. Deep tendon reflexes
Norepinephrine primarily affects vascular tone and cardiac output. Deep tendon reflexes are not a priority assessment for this medication.

C. IV Insertion site
Norepinephrine is a vasopressor, and extravasation can cause severe tissue necrosis. Frequent monitoring of the IV site is necessary to prevent complications.

D. Blood pressure and heart rate
Norepinephrine increases blood pressure and heart rate through vasoconstriction. Continuous monitoring is required to assess for excessive hypertension, tachycardia, or inadequate response to therapy.

E. Hourly urine output
Urine output is an essential indicator of organ perfusion. Since norepinephrine is used to maintain adequate blood pressure and perfusion in septic shock, monitoring urine output helps assess the effectiveness of treatment.

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Which of the following would the nurse understand is correct when implementing a primary assessment for clients suffering major trauma? The primary assessment:

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who presents with a chemical burn to the right hand, what should the nurse do first?

Correct Answer is D

Explanation

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Correct Answer is ["C","D","E"]

Explanation

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