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 ["B","C","E"]

Explanation

A. Change in moles can indicate skin cancer.
B. Change in bowel pattern can be a sign of colorectal cancer.
C. A nonhealing sore can indicate skin cancer or other types of cancer that manifest as chronic wounds.
D. Bloating is less specific and may indicate various health conditions but are not typically primary signs of cancer.
E. Nagging cough is can be a sign of lung and/or throat cancer.

A. A conscious adult client who has second-degree burns on both lower legs; respiratory rate is > 30/min B. A conscious adult client wearing a medic-alert diabetic bracelet, client reports feeling clammy and shaky. C. An unconscious adult client who has a large head wound with gray matter exposed; absent respirations D. An unconscious 6-month-old infant with no respirations, no visible injuries

Correct Answer is C

Explanation

A. This client has significant burns but is conscious and breathing, indicating adequate airway and respiratory effort.
B. This client is conscious but has symptoms potentially related to hypoglycemia rather than life-threatening injuries.
C. This client is unconscious with a severe head injury and absent respirations, indicating a compromised airway and immediate life-threatening condition.
D. This infant is unconscious with no respirations, requiring immediate attention but is not as urgent as the client with the severe head injury and compromised airway.

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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

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Correct Answer is ["B","C","E"]

Explanation

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Correct Answer is C

Explanation

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