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.
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.
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 ["125"]
Explanation
To calculate the infusion rate for an IV, the total volume to be infused (in this case, 1000 mL) is divided by the total time of infusion (8 hours). So, the calculation would be 1000 mL divided by 8 hours, which equals 125 mL per hour.
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