Evolve HESI Leadership- Prioritizing Care Practice Test

The priority nursing actions following a secondary survey for a trauma client with a penetrating wound are to document findings and assess vital signs. After the initial assessment and life-saving interventions have been performed during the primary survey, the secondary survey allows for a more thorough evaluation of the patient. Documenting findings is crucial for legal, clinical, and continuity of care purposes, ensuring that each step of the assessment is recorded and communicated effectively among the care team.

Assessing vital signs is essential in this context because it helps establish the patient’s hemodynamic status, detect any deteriorating condition early, and guide further management. For a trauma patient, changes in vital signs can indicate significant complications, such as hemorrhagic shock or other traumatic injuries that may not be immediately apparent.

While administering medications and ordering labs are important components of trauma care, they typically follow the initial evaluations and stabilization efforts where findings are documented. Communication with the physician and family is also necessary but should be prioritized after critical assessments and documentation are completed. A complete head-to-toe assessment is part of the secondary survey, but without documenting and assessing vitals first, the essential information may not be captured effectively.