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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Free Nursing Study Resources

Correct Answer is ["5"]

Explanation

To calculate the infusion time for a 1-L bag of 0.9% sodium chloride at a rate of 200 mL/hr, you would divide the total volume of the IV bag by the hourly infusion rate. Since there are 1000 mL in a 1-L bag, you would calculate 1000 mL divided by 200 mL/hr, which equals 5 hours.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

The client is at risk for developing pressure injury and foot drop. Given the client's history of a recent cerebrovascular accident (CVA) and the inability to reposition themselves, there is a heightened risk for pressure injuries due to prolonged periods of immobility. Additionally, the observed occasional movement of the left arm and leg with the right side without movement suggests a potential for muscle weakness or paralysis, which can lead to foot drop, characterized by difficulty in lifting the front part of the foot.

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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

Correct Answer is ["5"]

Explanation

A nurse on a medical-surgical unit is caring for a client. Exhibits Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing dropdown and dropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

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.