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 A
Explanation
A. In mass casualty triage, priority is given to clients who are salvageable with immediate intervention. This client is conscious (airway is intact) but has respiratory distress (RR > 30/min), suggesting potential inhalation injury or early shock. Prompt treatment can be life-saving.
B. This client is conscious but has symptoms potentially related to hypoglycemia rather than life-threatening injuries.
C.Unconscious adult with large head wound and exposed gray matter, absent respirationsis unsalvageable; in triage terms, this client would be black tag (expectant). Immediate care will not change survival.
D.Unconscious 6-month-old infant with no respirations, no visible injuriesis also considered unsalvageable without immediate resuscitation; triage prioritizes those with highest likelihood of survival.
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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