The client is a 26-year-old female who fell from an apartment balcony. She was transported to the hospital via ambulance.
The client enters the emergency room on a stretcher and is met in the trauma bay by the nurse.
What two actions should the nurse take first during the primary survey?
Stabilize the cervical spine.
Check for a pulse.
Request an x-ray.
Assess the respiratory rate.
Examine the abdomen.
Ensure the airway is patent.
Correct Answer : A,F
Choice A rationale
Stabilizing the cervical spine is one of the first actions that should be taken during the primary survey of a trauma patient. This is to prevent any potential injury to the spinal cord, which could result in permanent paralysis.
Choice B rationale
Checking for a pulse is an important part of the primary survey, but it is not one of the first actions that should be taken. The first priority is to ensure that the airway is patent and the cervical spine is stabilized.
Choice C rationale
Requesting an x-ray is not one of the first actions that should be taken during the primary survey. The first priority is to assess the client’s airway, breathing, and circulation, and to stabilize the cervical spine.
Choice D rationale
Assessing the respiratory rate is an important part of the primary survey, but it is not one of the first actions that should be taken. The first priority is to ensure that the airway is patent and the cervical spine is stabilized.
Choice E rationale
Examining the abdomen is an important part of the secondary survey, which is conducted after the primary survey. The first priority during the primary survey is to assess the client’s airway, breathing, and circulation, and to stabilize the cervical spine.
Choice F rationale
Ensuring that the airway is patent is one of the first actions that should be taken during the primary survey. This is to ensure that the client is able to breathe effectively and receive adequate oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Nadolol is a beta-blocker that can decrease heart rate and contractility, which can potentially exacerbate heart failure and lead to cardiogenic shock.
Choice B rationale
Captopril is an angiotensin-converting enzyme (ACE) inhibitor that is often used in the treatment of heart failure. It works by relaxing blood vessels and reducing the workload of the heart.
Choice C rationale
Digoxin is a cardiac glycoside that is used to treat heart failure and certain heart arrhythmias. It works by increasing the force of the heart’s contractions, which can improve heart function.
Choice D rationale
Hydrochlorothiazide is a diuretic that is often used in the treatment of heart failure. It works by helping the body get rid of excess fluid, which can reduce the workload of the heart.
Correct Answer is D
Explanation
Choice A rationale
While a case management evaluation of the client’s home environment could potentially identify areas for improvement, it may not directly address the caregiver’s immediate need for relief from their caregiving responsibilities. The caregiver is experiencing sleepless nights and frequent bouts of crying, which could be signs of caregiver burnout or depression. Therefore, immediate respite care may be more beneficial.
Choice B rationale
Employing a private duty nurse for respite could provide temporary relief for the caregiver. However, this option might not be feasible due to potential financial constraints. Additionally, it may not provide the caregiver with the emotional support they may need.
Choice C rationale
Proposing that extended family could relocate to the area to provide support is a potential long-term solution. However, it may not be feasible or practical for extended family members to relocate. This option also does not address the caregiver’s immediate need for relief and support.
Choice D rationale
Advising the caregiver to contact social services to locate a respite care facility for the client could provide the caregiver with the immediate relief they need. Respite care facilities offer temporary relief for caregivers by providing short-term care for the individual they are caring for. This would allow the caregiver to rest and take care of their own needs, which could help alleviate their symptoms of sleepless nights and frequent bouts of crying.
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