The nurse is working in the emergency department, and is anticipating the arrival of a client who fell from a second story window. The priority of care for this client upon arrival would be:
1. Assessing the blood pressure.
2. Determining level of consciousness.
3. Establishing and maintaining a patent airway.
4. Examining the client for blood loss.
Answer: 3
1. Assessing vital signs is completed once the airway is established.
2. Determining level of consciousness is completed during the neurological assessment after the airway is deemed patent.
3. The priority nursing action for any victim of trauma is establishing and maintaining an airway.
4. Checking for blood loss would be completed during the total body assessment, but would be a priority if the blood pressure were low.
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