During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next?

Examine the patient for any external bleeding.

Check the patient's level of consciousness.

Palpate extremities for bilateral pulses.

Observe the patient's respiratory effort

Answer and Explanation

The Correct Answer is D

A. While external bleeding is important to assess and manage, it is not the next immediate action after confirming an unobstructed airway.
B. Checking the patient's level of consciousness should be done after assessing the respiratory effort.
C. Palpating extremities for bilateral pulses is part of assessing circulation, which typically follows the assessment of consciousness.
D. After ensuring the patient has an unobstructed airway, the next step in the primary assessment is to observe the patient's respiratory effort. This is crucial as it provides immediate information about the adequacy of the patient's breathing and the need for supplemental oxygen or other interventions.

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Correct Answer is ["125"]

Explanation

To calculate the infusion rate for an IV, the total volume to be infused (in this case, 1000 mL) is divided by the total time of infusion (8 hours). So, the calculation would be 1000 mL divided by 8 hours, which equals 125 mL per hour.

A. A patient with a blue tag B. A patient with a black tag C. A patient with a yellow tag D. A patient with a red tag

Correct Answer is D

Explanation

A. A patient with a blue tag indicates minor injuries or illness and can wait for treatment.
B. A patient with a black tag is typically deceased or expected to die and is not a priority for immediate assessment.
C. A patient with a yellow tag indicates delayed treatment needs and can wait while more urgent cases are addressed.
D. A patient with a red tag indicates critical and life-threatening injuries requiring immediate assessment and intervention.

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During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient has an unobstructed airway. Which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer 0.45% sodium chloride (NaCl) 1000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

Correct Answer is ["125"]

Explanation

Following an earthquake, patients are triaged by emergency medical personnel and transported to the emergency department (ED). Which patient will the nurse need to assess first?

Correct Answer is D

Explanation

A nurse is caring for an older adult client who has a WBC count of 2,000/mm3 after three rounds of chemotherapy. Which of the following actions should the nurse take?

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A nurse is caring for a client who has been exposed to an unknown chemical. Which of the following actions should the nurse take?