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. Vegetarian lasagna with cheese and spinach, tossed green salad with ranch dressing, and fresh fruit. B. Lean hamburger with cheese, tomato, and lettuce on a whole-wheat bun, and angel food cake. C. Fried chicken breast, mashed potatoes, green beans, sliced tomatoes, and fresh apple pie. D. Grilled fish with whole-grain brown rice, steamed broccoli, and pear poached in red wine.

Correct Answer is D

Explanation

A. Vegetarian lasagna with cheese and spinach, tossed green salad with ranch dressing, and fresh fruit. This meal option contains carbohydrates from the lasagna, salad dressing, and fruit, which can raise blood glucose levels.
B. Lean hamburger with cheese, tomato, and lettuce on a whole-wheat bun, and angel food cake.

This meal option contains carbohydrates from the bun and angel food cake, which can raise blood glucose levels.
C. Fried chicken breast, mashed potatoes, green beans, sliced tomatoes, and fresh apple pie. This meal option contains significant amounts of carbohydrates from mashed potatoes and apple pie, which can raise blood glucose levels.
D. Grilled fish with whole-grain brown rice, steamed broccoli, and pear poached in red wine.

This meal option is lower in carbohydrates and contains healthier choices for a client with diabetes, helping to control blood glucose levels more effectively.

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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

Correct Answer is D

Explanation

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The nurse who is working in the emergency department is obtaining evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library. Which intervention is most important for the nurse to implement?

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.