During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?

Send blood to the lab for a complete blood count.

Finish the airway, breathing, circulation, disability survey.

Assess further for a cause of the decreased circulation,

Start normal saline fluid infusion with a large bore IV line.

Answer and Explanation

The Correct Answer is C

A. Sending blood to the lab for a complete blood count can wait until after immediate stabilization measures are initiated.
B. Finishing the primary survey is important, but the absent pulses and swollen leg suggest a critical vascular issue that needs immediate attention.
C. Assessing further for the cause of decreased circulation is the next step to determine if immediate intervention such as surgical consultation or revascularization is needed.
D. Starting normal saline infusion may be necessary later, but determining the cause of decreased circulation takes priority to prevent potential limb loss.

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Correct Answer is C

Explanation

A. While painful, a simple fracture and scratches do not pose an immediate threat to life compared to other injuries.
B. The client with severe head injuries and a low respiratory rate may seem like a priority, but if they are unresponsive and have a respiratory rate as low as 6/min, they may be beyond help.
C. A punctured chest with an audible hissing sound indicates a potential tension pneumothorax, a life-threatening condition that requires immediate intervention to prevent collapse of the lung and other potentially fatal complications.
D. A pregnant woman with cuts and abrasions should be evaluated promptly but is not as critical as clients with severe head injuries or tension pneumothorax.

A. A conscious adult client who reports shortness of breath, has a respiratory rate of 24/min, and capillary refill of <2 seconds B. A conscious adult client who has a dislocated right shoulder, respiratory rate of 18/min, and capillary refill of <2 seconds C. An unconscious adult client who has a sucking chest wound, respirations of 38/min, and capillary refill of <2 seconds D. An unconscious adult client who has no respirations, capillary refill is 2 seconds and paramedics have already tried to reposition airway without results

Correct Answer is C

Explanation

A. This client has respiratory distress but is conscious and stable, requiring urgent but not immediate attention compared to other critical conditions.
B. This client has a dislocated shoulder, which is painful and needs attention but is not life-threatening compared to other conditions.
C. This client is unconscious with a sucking chest wound and high respiratory rate, indicating severe respiratory compromise and needing immediate intervention to prevent further deterioration.
D. This client is also unconscious with no respirations despite attempted airway management, indicating a need for immediate resuscitative efforts, potentially including CPR.

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During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?

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During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?