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","D","E","G"]
Explanation
A. Inserting a nasogastric (NG) tube is not a priority action in the initial management of sepsis.
B. Measuring lactate levels is a priority action in the initial management of sepsis. Elevated lactate levels indicate tissue hypoxia and are associated with increased mortality in septic patients.
C. Obtaining a wound culture is not a priority action in the initial management of sepsis.
D. Administering broad-spectrum antibiotics is a priority action in the initial management of sepsis. Prompt antibiotic therapy is associated with improved outcomes in septic patients.
E. Obtaining blood cultures is a priority action in the initial management of sepsis. Blood cultures help identify the causative organism and guide antibiotic therapy.
F. Type and cross-matching for packed RBCs is not a priority action in the initial management of sepsis.
G. Rapidly administering 30 mL/kg of normal saline is a priority action in the initial management of sepsis. This bolus of fluid helps restore tissue perfusion and hemodynamic stability.
H. Obtaining a urine specimen is not a priority action in the initial management of sepsis.
Correct Answer is ["A","B","D"]
Explanation
A. This may indicate a pneumothorax, which is a potential complication of thoracentesis.
B. A heart rate of 110/min may indicate tachycardia, which can be a sign of hypoxia or other complications.
C. While oxygen saturation of 95% is within the normal range, it is slightly lower than expected for a patient with respiratory distress.
D. This may indicate air leakage into the subcutaneous tissue, which can be a sign of a pneumothorax or other complications.
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