After completing the secondary survey for a penetrating wound, which nursing action would be prioritized?

• A. Documenting the client's care
• B. Formulating the client's plan of care
• C. Reassessing the client's level of consciousness
• D. Administering tetanus prophylaxis to the client

Answer: (A)

The main idea here is that thorough documentation follows closely after completing the secondary survey in trauma care. Once you’ve finished your comprehensive head‑to‑toe assessment, recorded findings, and any interventions or observations, the priority is to document everything clearly and accurately. This creates a solid, shareable record of the patient’s status, the mechanism and location of the penetrating wound, neuro and circulatory status, vital signs, labs or imaging results, and any treatments given (such as tetanus status and prophylaxis). Good documentation ensures seamless communication among the care team, supports the ongoing plan, and provides legal protection.

While other actions like reassessing consciousness or administering tetanus prophylaxis are important parts of wound care and ongoing management, they occur within the broader care process, and the immediate, defining step after the secondary survey is to capture all those details in the record so the plan can be formulated and implemented based on accurate information.