Assessment of a 12-year-old who crashed his bicycle without
a helmet reveals the following: temperature 99.2°F, pulse 100 bpm, respiratory
rate 24 breaths per minute with easy work of breathing, and BP 102/70 mm Hg.
What is the priority action by the nurse?
a. Assess neurologic status while observing for obvious
injuries. b. Administer IV fluid bolus of normal saline at 20 mL/kg. c. Remove
the cervical collar if he complains that it bothers him. d. Listen for bowel
sounds while assessing for pain