Exhibits

Following the fluid bolus, the client is more awake and able to answer questions. What questions are appropriate for the secondary survey? Select all that apply.

Do you take any medications?

What happened before you fell?

What was your last meal?

Is it possible that you are pregnant?

Do you live with anyone?

Are you fully insured?

Answer and Explanation

Correct Answer : A,B,C,D,E

-   A) Knowing the medications the patient takes is crucial for understanding her medical history and any potential interactions with treatments that may be administered.

-   B) Understanding the events leading up to the fall can help in assessing the cause and potential injuries sustained, which is important for her current and future treatment plans.

-   C) Information about the last meal is important for anesthesia considerations, in case surgery is required, and for understanding the patient's nutritional status.
-   D) Knowing if the patient is pregnant is vital as it influences the management of her care and the urgency of certain tests, as well as the avoidance of potential harm to the fetus.
-   E) Information about cohabitants can be useful for social support and may also provide additional information about the circumstances leading to the injury.
-   F) While insurance status is a practical consideration, it is not clinically relevant to the secondary survey and immediate care of the patient. Therefore, it is not an appropriate question at this stage.

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Correct Answer is C

Explanation

A. Demonstrating how to palpate the popliteal pulse is not a suitable alternative for measuring blood pressure when the client cannot be measured in the arms or legs. Palpating peripheral pulses does not provide accurate blood pressure measurements.

B. Advising the UAP to document the last blood pressure obtained is insufficient because it does not address the need for current blood pressure monitoring. Documentation of past
measurements does not provide real-time information about the client's hemodynamic status.

C. Estimating the blood pressure by assessing the pulse volume of the client's radial pulses is a reasonable alternative when traditional blood pressure measurement sites are inaccessible. Although not as accurate as traditional methods, assessing the strength of peripheral pulses can provide valuable information about perfusion and blood pressure status.

D. Documenting why the blood pressure cannot be accurately measured is important for record- keeping but does not address the need for ongoing blood pressure monitoring or provide an alternative method for assessment.

A. Measure the respiratory rate B. Palpate the abdomen C. Check the airway for patency D. Feel for a pulse E. Stabilize the cervical spine F. Call for an x-ray

Correct Answer is ["C","E"]

Explanation

A. Measure the respiratory rate

While important, measuring the respiratory rate is not the first priority in the primary survey of trauma assessment.
B. Palpate the abdomen

Palpating the abdomen is part of the secondary survey in trauma care, which comes after the primary survey and initial stabilization.
C. Check the airway for patency

The first step in the primary survey (ABCDE approach) is to check the airway to ensure it is patent. If the airway is not clear, the patient cannot breathe, and immediate intervention is needed.
D. Feel for a pulse

While checking circulation (which includes feeling for a pulse) is important, it comes after ensuring the airway and cervical spine are addressed.
E. Stabilize the cervical spine

In trauma patients, particularly those with falls or other significant mechanisms of injury, stabilizing the cervical spine is crucial to prevent potential spinal cord injury.
F. Call for an x-ray

Ordering imaging studies is important but is not part of the initial primary survey, which focuses on immediate life-threatening conditions.

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Exhibits Following the fluid bolus, the client is more awake and able to answer questions. What questions are appropriate for the secondary survey? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position. Which action should the nurse implement?

Correct Answer is C

Explanation

The client is a 26-year-old female who fell from an apartment balcony. She was transported to the hospital via ambulance. The client enters the emergency room on a stretcher and is met in the trauma bay by the nurse. For the primary survey, what 2 things should the nurse do first?

Correct Answer is ["C","E"]

Explanation

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Exhibits

Following the fluid bolus, the client is more awake and able to answer questions. What questions are appropriate for the secondary survey? Select all that apply.