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","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.

A. Begin abdominal girth measurements. B. Review serum protein levels. C. Assess neurological status. D. Initiate antibiotic therapy.

Correct Answer is D

Explanation

A. Begin abdominal girth measurements.
Abdominal girth measurements may be important for assessing fluid status in clients with liver disease and ascites, but in this case, the elevated polymorphonuclear leukocyte count indicates a possible infection, requiring immediate intervention.

B. Review serum protein levels.
While monitoring serum protein levels is important in clients with liver disease, the priority in this situation is to address the potential infection indicated by the elevated leukocyte count.

C. Assess neurological status.
Neurological assessment may be relevant in some cases, but it is not the priority in a client with suspected infection after a paracentesis.

D. Initiate antibiotic therapy.
Given the client's symptoms and the elevated polymorphonuclear leukocyte count in the ascitic fluid, indicating possible infection (spontaneous bacterial peritonitis), initiating antibiotic therapy is the priority action to address the infection and prevent further complications.

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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 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

The nurse is caring for a client with decompensated liver disease who is experiencing fever, chills, and abdominal tenderness. Following a paracentesis, the nurse receives laboratory results. Exhibits After notifying the healthcare provider, which action should the nurse take next?

Correct Answer is D

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.