NursingPlex
    Sign In
    HESI RN EXIT 3 PROCTORED EXAMQuestion 110
    110 / 120
    HESI RN EXIT 3 PROCTORED EXAM
    Select All That Apply

    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. For the primary survey, what 2 things should the nurse do first?

    Explanation & Rationale

    A. Measure the respiratory rate While important, measuring the respiratory rate is not the first priority in the primary survey of trauma assessment. B. Palpate the abdomen Palpating the abdomen is part of the secondary survey in trauma care, which comes after the primary survey and initial stabilization. C. Check the airway for patency The first step in the primary survey (ABCDE approach) is to check the airway to ensure it is patent. If the airway is not clear, the patient cannot breathe, and immediate intervention is needed. D. Feel for a pulse While checking circulation (which includes feeling for a pulse) is important, it comes after ensuring the airway and cervical spine are addressed. E. Stabilize the cervical spine In trauma patients, particularly those with falls or other significant mechanisms of injury, stabilizing the cervical spine is crucial to prevent potential spinal cord injury. F. Call for an x-ray Ordering imaging studies is important but is not part of the initial primary survey, which focuses on immediate life-threatening conditions.

    🔒 Submit your answer to reveal