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. Monitoring vital signs every 8 hours is not sufficient for a client undergoing a stem cell transplant, who requires frequent assessment due to potential complications.
B. Providing the client with water is important, but specific fluid volumes and intervals depend on individual needs and should not be standardized.
C. Clients undergoing stem cell transplants are immunocompromised due to chemotherapy and conditioning regimens. To reduce the risk of infection, all equipment that comes into contact with the client, such as blood pressure cuffs, should be dedicated to that room only. This prevents cross-contamination from other patients.
D. Negative pressure rooms are for protecting others from airborne infections (e.g., TB). Stem cell transplant clients require positive pressure rooms to protect them from pathogens in the environment.

A. Guarded B. Good C. Very good D. Poor E. None F. None

Correct Answer is D

Explanation

A. Guardedsuggests uncertainty, which may understate the seriousness of stage IV disease.
B. "Good" and "very good" prognoses suggest favorable outcomes, which are less likely with stage IV ovarian cancer.
C. "Poor" prognosis indicates a bleak outlook with limited treatment options and expected decline in health.
D.Stage IV ovarian cancer indicates advanced disease with metastasis to distant organs, such as the liver or lungs. Even with aggressive treatment (surgery, radiation, chemotherapy), the overall survival rate is low, and the prognosis is considered poor. Discussing a poor prognosis allows the client to make informed decisions about treatment options, advance care planning, and supportive care.

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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 planning care for a client who is to undergone a stem cell transplant. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A client is receiving treatment for stage IV ovarian cancer and asks the nurse to discuss her prognosis. The client plans to have aggressive surgical, radiation, and chemotherapy treatments. Which of the following prognoses should the nurse discuss with the client?

Correct Answer is D

Explanation

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