The nurse observes that the patient's right pedal pulses are absent and the leg is swollen. The nurse's first action should be to:

  1. Obtain a Glasgow Score
  2. Attach an EKG
  3. Order an isotonic fluid infusion through two large-bore IV lines
  4. Proceed with a survey
Explanation

This assessment may indicate the patient has an arterial trauma and hemorrhage. Since this is a possibly life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a CBC is indicated, administration of IV fluids should be started first. The nurse can complete the primary survey and further assessment after the IV fluids are initiated.

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