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 C

Explanation

A. Humidifying the client's room helps to maintain adequate moisture levels in the air. However, it is not specifically related to low WBC counts.
B. Cleaning dentures in a denture cup and serving cooked fruit with meals are good practices for hygiene and dietary considerations but do not directly address infection control.
C. Serving cooked fruit with meals can help minimize the risk of foodborne illnesses.
D. Replacing the water in flower vases with fresh water daily is important for preventing bacterial growth but is not as directly beneficial for infection prevention in this context.

A. Mental status assessment B. Nutritional assessment C. An environmental health assessment D. Faith based assessment

Correct Answer is C

Explanation

A. Mental status assessment involves evaluating a client's cognitive and emotional function.
B. Nutritional assessment involves evaluating a client's dietary intake and nutritional status.
C. An environmental health assessment involves assessing exposure to environmental hazards such as chemicals and pollutants.
D. Faith-based assessment involves exploring a client's religious or spiritual beliefs and practices.

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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?

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Naxlex Comprehensive Predictor Exams

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