During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next?
a. Palpate extremities for bilateral pulses.
b. Observe the patient's respiratory effort.
c. Check the patient's level of consciousness.
d. Examine the patient for any external bleeding.
ANS: B
Even with a patent airway, patients can have other problems that compromise ventilation, so the next action is to assess the patient's breathing. The other actions are also part of the initial survey but assessment of breathing should be done immediately after assessing for airway patency.
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1. Support elevated protein needs. 2. Maintain on intravenous fluids and clear liquids. 3. Limit food and fluid intake to three mealtimes daily. 4. Begin a weight-reduction program immediately.
To maintain optimal thermoregulation for the premature infant, the nurse should
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An older patient, recovering from surgery, is prescribed a soft diet. The nurse realizes that this diet supports which age-related change?
1. decline in gastric motility 2. reduced intestinal absorption 3. lactose intolerance 4. gall bladder insufficiency
The nurse needs to apply a warm moist compress to an open draining wound. Place suitable nursing interventions for the compress in the proper order for moist heat application
1. Apply clean gloves. 2. Apply sterile gloves. 3. Add sterile gauze to basin. 4. Fill the basin with warm water. 5. Pour sterile solution into sterile basin. 6. Remove existing dressing and discard.