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 A

Explanation

A. The erythrocyte sedimentation rate (ESR) is a marker of inflammation and is used to monitor the effectiveness of anti-inflammatory treatments such as aspirin in clients with rheumatoid arthritis.
B. Antinuclear antibody (ANA) is used to diagnose autoimmune diseases but is not typically monitored for the effectiveness of aspirin therapy in RA.
C. Rheumatoid factor (RF) is used for the diagnosis of RA, but it does not change significantly with treatment.
D. White blood cell (WBC) count is not a specific marker for monitoring the effectiveness of aspirin in treating RA.

A. Urine output of175 mL in the past 8 hr B. Urine output of 2,200 mL in the past 24 hr C. First-voided urine in the morning has a strong odor D. Urine is cloudy after sitting in the urinal for 6 hr

Correct Answer is A

Explanation

A. Urine output of 175 mL in the past 8 hours is significantly low and indicates potential acute kidney injury or worsening renal function, requiring immediate notification to the provider.
B. Urine output of 2,200 mL in the past 24 hours is within normal limits.
C. Strong odor in the first-voided urine in the morning is common and not necessarily indicative of a problem.
D. Cloudy urine after sitting in the urinal for several hours can occur due to crystallization or bacterial growth and is not a critical finding.

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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 an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication?

Correct Answer is A

Explanation

A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider?

Correct Answer is A

Explanation

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 nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene?

A nurse is teaching a client who has hypertension and a new prescription for atenolol. Which of the following findings should the nurse include as adverse effects of this medication?

A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene?

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Exhibits The nurse collects blood from the client during peripheral IV line placement. What laboratory specimens would the nurse expect for the provider to order? Select all that apply.

A nurse is teaching the partner of a client who had a stroke about dysphagia. Which of the following statements by the client's partner should indicate to the nurse that the teaching was effective?

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.