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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.

Answer and Explanation

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.

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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.

A. Increased respiratory rate B. Increase hematocrit C. Increased blood pressure D. Increased temperature E. Increased Heart Rate

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

Explanation

A. Fluid overload can lead to pulmonary edema and difficulty breathing, resulting in an increased respiratory rate.
B. Fluid overload typically leads to dilution of blood, which can result in a decreased hematocrit.
C. Fluid overload can lead to increased blood volume and increased pressure on the blood vessel walls, resulting in increased blood pressure.
D. Fluid overload is not typically associated with an increased body temperature.
E. Fluid overload can lead to increased blood volume and increased pressure on the heart, resulting in an increased heart rate.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 1-day postoperative following a total laryngectomy and has begun a soft diet. The client is not eating well and tells the nurse that the hospital food has no taste. Which of the following responses is appropriate for the nurse to make?

Correct Answer is D

Explanation

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

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

Explanation

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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.)