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 B
Explanation
A. Fentanyl, an opioid, typically causes pupillary constriction, not dilation. This is known as miosis.
B. Fentanyl can cause bradycardia or tachycardia, but tachycardia is more common in acute toxicity.
C. Fentanyl is more likely to cause hypotension (low blood pressure) rather than hypertension (high blood pressure).
D. Fentanyl can cause respiratory depression, leading to hypoventilation and possibly bradypnea or apnea, but tachypnea (rapid breathing) is less likely to occur as a direct effect of fentanyl toxicity.
Correct Answer is A
Explanation
A. This behavior reflects the secretive and recurring nature of binge-purge cycles characteristic of bulimia nervosa. The condition often involves a pattern of eating large amounts of food (binging) followed by compensatory behaviors such as self-induced vomiting (purging) to prevent weight gain.
B. This statement is not characteristic of bulimia nervosa.
C. This statement could indicate laxative abuse, which may occur in individuals with bulimia nervosa, but it is not specific to the disorder.
D. This statement could indicate anorexia nervosa, which is characterized by restrictive eating, but it is not specific to bulimia nervosa.
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