Exhibits

The nurse inspects the airway. There is no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.

A Allergies

B Circulation

C Neurological status

D Ventilation

E Current medications

F Exposure

Answer and Explanation

Correct Answer : B,D,E

A. Allergies
Allergies are important to know but are not part of the primary survey. The primary survey focuses on immediate life threats, such as airway, breathing, and circulation, rather than detailed background information.
B. Circulation
Assessment of circulation is critical in the primary survey to identify and manage life-threatening conditions such as shock or severe bleeding. It includes evaluating blood pressure, heart rate, and peripheral pulses to assess the effectiveness of the cardiovascular system.
C. Neurological status
While neurological status is important, it is part of a secondary survey rather than the primary survey. The primary survey focuses on immediate life-threatening conditions, while the neurological status is assessed more thoroughly in the secondary survey.
D. Ventilation
Assessing ventilation is a crucial part of the primary survey. This involves checking the client's breathing rate, depth, and effectiveness to ensure adequate oxygenation and addressing any immediate respiratory distress.
E. Current medications
Knowing current medications is important for overall care but is not part of the primary survey. The primary survey addresses life-threatening conditions rather than details of medication history.
F. Exposure
Exposure is part of the primary survey, ensuring that the client is completely exposed for a thorough assessment while protecting their privacy and warmth. It involves checking for hidden injuries and ensuring the client’s environment is safe.

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

Explanation

A. Providing information on medication effects is within the nurse's scope of practice and does not typically require social work involvement.
B. Client B, who is hospitalized and wishes to keep up with school assignments, may need assistance with educational continuity plans.
C. Securing an emergency notification system involves social services to assess and arrange appropriate services.
D. Providing breastfeeding instructions is part of nursing care and does not typically require social work involvement.
E. Placement in an assisted living facility requires social work assistance to coordinate appropriate care and transition.

Correct Answer is ["0.5"]

Explanation

To administer the correct dose of lorazepam, which is 1 mg, when only 2 mg tablets are available, the nurse should administer half a tablet. This is because each tablet contains 2 mg of lorazepam, and the prescribed dose is 1 mg. Therefore, dividing the tablet into two equal parts will provide the necessary 1 mg dose. The answer, rounded to the nearest tenth as per the instruction, is 0.5.

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Exhibits The nurse inspects the airway. There is no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of clients. Which of the following clients should the nurse refer to a social worker? (Select all that apply.)

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

Explanation

A nurse is preparing to administer lorazepam 1 mg PO at bedtime. The amount available is lorazepam 2 mg tablets. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.5"]

Explanation

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Exhibits

The nurse inspects the airway. There is no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.