Which of the following would the nurse understand is correct when implementing a primary assessment for clients suffering major trauma? The primary assessment:

includes the head-to-toe anterior and posterior assessment.

priorities are continuing and ongoing but treatment will be deferred if the clients unstables

is focused on airway maintenance and ventilation effectiveness.

focuses on the ABCDs of the client to identify life threatening problems

Answer and Explanation

The Correct Answer is D

A. includes the head-to-toe anterior and posterior assessment.
This describes a secondary assessment, not a primary one. The primary assessment focuses on the immediate life-threatening issues rather than a full head-to-toe examination.

B. priorities are continuing and ongoing but treatment will be deferred if the client is unstable.
In primary assessment, treatment should not be deferred in unstable clients. Immediate treatment and stabilization take priority.

C. is focused on airway maintenance and ventilation effectiveness.
As airway and ventilation are key aspects of the primary assessment (known as the "ABC" of trauma: Airway, Breathing, Circulation). However, it does not cover all of the primary assessment areas.

D. focuses on the ABCDs of the client to identify life-threatening problems.
The primary assessment is focused on identifying life-threatening problems using the ABCDs (Airway, Breathing, Circulation, Disability).

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Correct Answer is C

Explanation

A. Epinephrine 1 mg IV
Epinephrine is used for severe anaphylaxis. This reaction is more consistent with a mild allergic (febrile) transfusion reaction, which does not require epinephrine.

B. Acetaminophen 650 mg PO
Acetaminophen is used for febrile reactions but does not treat the allergic symptoms (itching, urticaria).

C. Diphenhydramine 50 mg IV
Diphenhydramine (Benadryl) is given to treat mild allergic transfusion reactions such as flushing, itching, and urticaria.

D. Furosemide 40 mg PO
Furosemide (Lasix) is given between blood transfusions to prevent fluid overload, not for allergic reactions.

A. Massive blood loss leading to decreased oxygen delivery to tissues B. Severe allergic reaction causing systemic vasodilation and increased capillary permeability C. Infection causing a systemic inflammatory response leading to vasodilation and decreased tissue perfusion D. Cardiac failure resulting in inadequate tissue perfusion and oxygenation

Correct Answer is C

Explanation

A. Massive blood loss leading to decreased oxygen delivery to tissues

This describes hypovolemic shock, which occurs due to significant blood or fluid loss (e.g., hemorrhage, severe dehydration). In this scenario, there is no evidence of massive blood loss, making hypovolemic shock unlikely.

B. Severe allergic reaction causing systemic vasodilation and increased capillary permeability

This describes anaphylactic shock, which results from an acute allergic reaction (e.g., to food, medication, insect stings). There is no mention of an allergen exposure or symptoms like wheezing, stridor, or urticaria, making anaphylactic shock unlikely.

C. Infection causing a systemic inflammatory response leading to vasodilation and decreased tissue perfusion

This patient is exhibiting signs of septic shock, which occurs as a result of a severe infection leading to systemic inflammatory response syndrome (SIRS). The presence of fever, tachycardia, tachypnea, hypotension, and altered mental status strongly suggests sepsis progressing to septic shock.

D. Cardiac failure resulting in inadequate tissue perfusion and oxygenation

This describes cardiogenic shock, which occurs due to heart failure (e.g., from myocardial infarction, cardiomyopathy). It leads to low cardiac output, pulmonary congestion, and organ hypoperfusion. This patient’s infection and systemic inflammation suggest septic shock, not a primary cardiac event.

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Which of the following would the nurse understand is correct when implementing a primary assessment for clients suffering major trauma? The primary assessment:

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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