22. A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)

Establish IV access.

Open the airway using a jaw-thrust maneuver.

Remove clothing for a thorough assessment.

Perform a Glasgow Coma Scale assessment..

Determine effectiveness of ventilator efforts.

Answer and Explanation

The Correct Answer is B, E, D, A, C

B. The first action in a primary survey is to open the airway to ensure it is not obstructed, especially if the client is unconscious or has altered mental status.

E. Once the airway is secured, determining the effectiveness of ventilatory efforts is essential to ensure adequate oxygenation.

D. After airway and breathing are addressed, performing a Glasgow Coma Scale assessment helps determine the level of consciousness and neurological status.

A. Establishing IV access is crucial for fluid resuscitation and medication administration but is not the first step in a primary survey.

C. Finally, removing clothing is necessary for a thorough assessment, but it comes after the critical steps of airway, breathing, and circulation have been addressed.

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Correct Answer is D

Explanation

- A) Extension of the arms is incorrect because decorticate posturing is characterized by flexion into the body, not extension away from it.
- B) External rotation of the lower extremities is not associated with decorticate posturing, which involves movements primarily of the upper extremities.
- C) Pronation of the hands is incorrect as decorticate posturing typically involves flexion of the arms, wrists, and fingers into the chest.
- D) Plantar flexion of the legs is correct because decorticate posturing includes internal rotation and flexion of the arms and wrists, with the legs extended and feet plantar flexed.

A. Establish IV access. B. Open the airway using a jaw-thrust maneuver. C. Remove clothing for a thorough assessment. D. Perform a Glasgow Coma Scale assessment.. E. Determine effectiveness of ventilator efforts.

Correct Answer is B, E, D, A, C

Explanation

B. The first action in a primary survey is to open the airway to ensure it is not obstructed, especially if the client is unconscious or has altered mental status.

E. Once the airway is secured, determining the effectiveness of ventilatory efforts is essential to ensure adequate oxygenation.

D. After airway and breathing are addressed, performing a Glasgow Coma Scale assessment helps determine the level of consciousness and neurological status.

A. Establishing IV access is crucial for fluid resuscitation and medication administration but is not the first step in a primary survey.

C. Finally, removing clothing is necessary for a thorough assessment, but it comes after the critical steps of airway, breathing, and circulation have been addressed.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

Correct Answer is D

Explanation

Correct Answer is B, E, D, A, C

Explanation

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