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 D

Explanation

A. Continue to monitor the client as a paralytic ileus is possible

Paralytic ileus can occur postoperatively, but sudden severe pain and distension indicate a more serious issue, such as bowel infarction.

B. Administer the PRN stool softener to the client

A stool softener is inappropriate if the client has a possible bowel obstruction or ischemia.

C. Obtain an order to insert a nasogastric tube set to low suction

An NG tube may help relieve distension, but it does not treat the underlying cause. The priority is to notify the surgeon.

D. Report the assessment findings to the surgeon

Absent bowel sounds, severe pain, and distension suggest bowel ischemia, a life-threatening complication requiring immediate surgical intervention.

A. 20-gauge catheter in the the right wrist infusing IV antibiotics B. 20-gauge catheter in the the right forearm infusing 0.9% Normal Saline C. 22-gauge catheter in the left forearm infusing 0.45% Normal Saline D. 18-gauge infusing 20mg Potassium Chloride IV

Correct Answer is B

Explanation

A. 20-gauge catheter in the right wrist infusing IV antibiotics

Infusing antibiotics can cause incompatibilities.

B. 20-gauge catheter in the right forearm infusing 0.9% Normal Saline

A 20-gauge or larger catheter in a patent IV site with compatible fluid (NS) is required for PRBC transfusion.

C. 22-gauge catheter in the left forearm infusing 0.45% Normal Saline

A 22-gauge catheter is too small for safe transfusion.

D. 18-gauge infusing 20 mg Potassium Chloride IV

Potassium chloride infusion should not be interrupted, making this site unsuitable.

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