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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Potential Condition:
Hypovolemia: The client shows signs of hypovolemia such as a low blood pressure (94/56 mm Hg), a high heart rate (110/min), and a relatively high urine output (1500 mL in the last hour), which may indicate an over-diuresis or inadequate fluid replacement postoperatively.
Actions to Take:
Obtain prescription for IV bolus: Administering an IV fluid bolus can help restore intravascular volume, thereby increasing blood pressure and improving perfusion to vital organs.
Lower head of bed: This action helps to increase venous return to the heart, which can help improve cardiac output and blood pressure in a hypovolemic patient.
Parameters to Monitor:
Urinary output: This is a key indicator of kidney function and fluid status. Monitoring urine output will help determine if the client is adequately responding to fluid resuscitation and maintaining appropriate kidney function.
Blood pressure: Continuous blood pressure monitoring is essential to evaluate the effectiveness of interventions aimed at correcting hypovolemia and ensuring the client's hemodynamic stability.
Correct Answer is C
Explanation
A. Giving acetaminophen is appropriate for fever reduction but does not address the hypotension and potential dehydration in this scenario.
B. Providing oxygen is important, but the patient's hypotension requires fluid resuscitation as the initial priority.
C. Applying wet sheets and a fan are immediate actions focused on rapid cooling. The priority is to lower the body temperature as quickly as possible to prevent organ damage.
D. Starting lactated Ringer's solution at a high rate is crucial to address hypovolemia and to cool the patient effectively through intravenous hydration but should be done after cooling the patient using a wet sheet.
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