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.)
Determine effectiveness of ventilator efforts.
Remove clothing for a thorough assessment.
Open the airway using a jaw-thrust maneuver.
Perform a Glasgow Coma Scale assessment.
Control any external bleeding.
The Correct Answer is C,A,D,B,E
The correct order is C,A,D,B,E.
C. Open the airway using a jaw-thrust maneuver.
This is the first priority since maintaining a clear airway is critical for the client’s survival.
A. Determine effectiveness of ventilatory efforts.
After ensuring the airway is open, assess the client’s breathing and whether they are ventilating effectively.
D. Perform a Glasgow Coma Scale assessment.
This step evaluates the client’s neurological status to determine their level of consciousness and identify any brain injuries.
B. Remove clothing for a thorough assessment.
To expose the client for a comprehensive physical examination and assess any injuries.
E. Control any external bleeding.
As part of circulation management, identify and stop any significant bleeding to prevent shock. This step addresses the "C" in ABCDE.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Albumin is a protein that is produced by the liver and is a good indicator of nutritional status. TPN is intended to provide adequate nutrition to the patient, so an increase in albumin levels would indicate that the treatment is effective.
B. Calcium levels are not directly related to the effectiveness of TPN. Calcium levels can be affected by a variety of factors and are not a specific marker for the effectiveness of TPN.
C. Hematocrit (Hct) measures the percentage of red blood cells in the blood. It is not directly related to the effectiveness of TPN.
D. White blood cell count (WBC) is a marker of immune function and is not directly related to the effectiveness of TPN.
Correct Answer is D
Explanation
A. This response dismisses the client's concerns and does not address the underlying issue.
B. This response is appropriate, but it does not address the underlying issue of altered taste perception.
C. This response suggests a solution but does not address the underlying issue of altered taste perception.
D. This response acknowledges the client's concerns and provides an explanation for the altered taste perception, which can be reassuring and informative.
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