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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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale
While the patient’s currently prescribed medications are important information, they are not the most immediate concern in this situation. The healthcare provider will need this information, but it does not need to be the first piece of information provided.

Choice B rationale
The increasing confusion of the patient is the most immediate concern and should be communicated first. Confusion and disorientation can be signs of a serious condition such as a brain injury, especially following a fall. It is crucial to relay this information to the healthcare provider as soon as possible so that appropriate diagnostic tests can be ordered and treatment can be initiated.
Choice C rationale
The patient’s healthcare power of attorney is important information, especially if the patient’s condition worsens and they are unable to make decisions for themselves. However, this information does not need to be communicated first. The immediate concern is the patient’s medical condition.
Choice D rationale
The fall from a ladder is certainly important information as it provides context for the patient’s current condition. However, it does not need to be the first piece of information provided. The healthcare provider will likely infer that a fall has occurred based on the other information provided (e.g., confusion, potential loss of consciousness).

A. Administer IV fluids B. Assess the rash C. Administer an antihistamine D. Administer a steroid

Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale
Administering IV fluids is a potential nursing intervention for several body systems. For example, the circulatory system may require IV fluids to maintain blood volume and pressure. The renal system may need IV fluids to ensure adequate urine output. The digestive system might need IV fluids to compensate for losses from vomiting or diarrhea.
Choice B rationale
Assessing a rash is a potential nursing intervention for the integumentary system. Rashes can be a sign of many different conditions, including allergic reactions, infections, autoimmune diseases, and more. By assessing the rash, the nurse can gather information to help determine its cause and appropriate treatment.
Choice C rationale
Administering an antihistamine is a potential nursing intervention for the immune system. Antihistamines are often used to treat allergic reactions, which involve the immune system.

They can also be used to treat symptoms of the common cold, which is caused by a viral infection.
Choice D rationale
Administering a steroid is a potential nursing intervention for several body systems. Steroids can be used to reduce inflammation, which can benefit the musculoskeletal, integumentary, respiratory, and other systems. They can also be used to treat certain endocrine disorders.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is ["A","B","C","D"]

Explanation

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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?