When caring for a patient with multiple traumatic injuries, which of the following should the nurse do after adequately managing the patient's airway, breathing, and circulation?
1. listen to heart sounds
2. administer prophylactic tetanus toxoid
3. assess level of consciousness
4. transfer the patient to a high-acuity unit
3
Rationale: The purpose of the initial assessment or primary survey is to identify life-threatening conditions and intervene appropriately. Listening to heart sounds is part of the secondary survey, which follows the primary survey. Administering prophylactic tetanus toxoid and transferring the patient should happen after the assessment is complete. The nurse should assess the patient's neurological status or level of consciousness as the next step.
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