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 ["5"]

Explanation

To calculate the infusion time for a 1-L bag of 0.9% sodium chloride at a rate of 200 mL/hr, you would divide the total volume of the IV bag by the hourly infusion rate. Since there are 1000 mL in a 1-L bag, you would calculate 1000 mL divided by 200 mL/hr, which equals 5 hours.

A. Place the client's clothing in a plastic bag. B. Instruct the client to remove their clothing. C. Remain at least 1.8 meters (6 feet) from the client D. Shower and scrub the client's skin

Correct Answer is B

Explanation

A. Placing the client's clothing in a plastic bag may be necessary for preserving evidence but does not address immediate safety concerns.
B. Instructing the client to remove their clothing helps reduce further exposure to the unknown chemical.
C. Maintaining a safe distance from the client is important, but immediate decontamination is a higher priority.
D. Showering and scrubbing the client's skin should be done after removing contaminated clothing to minimize exposure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["5"]

Explanation

A nurse is caring for a client who has been exposed to an unknown chemical. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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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