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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:

A.

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

B.

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

C.

is focused on airway maintenance and ventilation effectiveness.

D.

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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Related Questions

Correct Answer is D

Explanation

A. Prepare for immediate surgery to repair the open fracture
Surgery may be necessary, but it is not the immediate priority. The focus should be on stabilizing the client and preventing further injury.

B. Assess for pulses in the upper and lower extremities
Assessing circulation is important but is not the most immediate life-saving intervention. First, the client must be stabilized and bleeding controlled.

C. Place a sterile pressure dressing on the open fracture
While controlling bleeding is important, spinal immobilization takes precedence in trauma cases to prevent potential spinal cord injury.

D. Maintain C-spine immobilization
In a trauma patient with loss of consciousness, cervical spine injury must be assumed. Immobilization prevents further damage while other interventions are performed.

Correct Answer is C

Explanation

A. 63% TBSA
This value is too high based on the Rule of Nines calculation.

B. 45% TBSA
This overestimates the burn area.

C. 36% TBSA
Using the Rule of Nines, the TBSA is calculated as follows:

  • Entire right arm (anterior + posterior): 9%
  • Posterior trunk: 18%
  • Posterior right leg: 9%
  • Total TBSA = 9% + 18% + 9% = 36%

D. 27% TBSA
This underestimates the affected areas.

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