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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.

Neurological status

Circulation

Current medications

Allergies

Exposure

Ventilation

Answer and Explanation

Correct Answer : A,B,E

A. Neurological status: Assessing the neurological status is crucial in the primary survey to

determine the client's level of consciousness, pupil reactions, and response to stimuli. This helps in identifying any potential brain injury or neurological deficits resulting from the fall.

B. Circulation: Evaluating circulation involves assessing the client's heart rate, blood pressure, and peripheral perfusion. In this scenario, the client's heart rate and blood pressure are provided in the nurse's notes, indicating the need to assess circulation as part of the primary survey.

C. Current medications: While important for the overall assessment and care of the client, assessing current medications is typically part of the secondary survey rather than the primary survey. The primary survey focuses on immediate life-threatening conditions.

D. Allergies: While allergies are essential information for the client's overall care, they are typically addressed during the secondary survey or during the history-taking process rather than as part of the primary survey.

E. Exposure: Assessing exposure involves ensuring the client is adequately covered and protected from environmental factors, especially in trauma situations where there may be significant blood loss or risk of hypothermia. This includes removing clothing to assess for additional injuries or bleeding.

F. Ventilation: While ventilation is crucial for assessing the client's respiratory status, including respiratory rate and effort, it is typically part of the primary survey rather than the primary survey itself. Assessing ventilation helps determine if the client is adequately breathing and oxygenating.

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Free Nursing Study Resources

Correct Answer is ["0.2"]

Explanation

Step-by-step Calculation:

We need to find the volume (in mL) of teriparatide that contains the desired dose of 60 mcg.
Set up the proportion:dose (mcg) / concentration (mcg/mL) = volume (mL)
Fill in the known values:
- Dose (mcg): 60 mcg (as given in the problem)
- Concentration (mcg/mL): 750 mcg/2.4 mL (from the medication label)
Solve for the volume:
- Multiply both sides of the proportion by the concentration to isolate the volume on the left:
- dose (mcg) = volume (mL) concentration (mcg/mL)
- Substitute the known values:
- 60 mcg = volume (mL) (750 mcg / 2.4 mL)
Calculate the volume:
- Divide both sides by the concentration to solve for the volume:
- volume (mL) = 60 mcg / (750 mcg / 2.4 mL)
- Simplify:
- volume (mL) = (60 mcg 2.4 mL) / 750 mcg
- volume (mL) = 0.192 mL (approximately)
Rounding (optional): The problem specifies rounding to the nearest tenth. Since 0.192 is closer to 0.2 than 0.1, the rounded volume is:
volume (mL) = 0.2 mL (rounded to one decimal place)

Therefore, the nurse should administer 0.2 mL of teriparatide.

Correct Answer is []

Explanation

Actions to Take:

A. Educate on disease process and management: Rheumatoid arthritis (RA) is a chronic

autoimmune disorder characterized by inflammation of the synovial membrane, leading to joint pain, swelling, and stiffness. Educating the client about RA helps them understand the disease, its

progression, treatment options, and the importance of adherence to prescribed medications and lifestyle modifications. This empowers the client to actively participate in managing their condition and improve outcomes.

B. Turn every two hours to offload bony prominences to prevent pressure injuries: Rheumatoid arthritis predisposes individuals to joint deformities and immobility due to joint inflammation and pain. Immobility increases the risk of pressure injuries, especially over bony prominences. Turning the client every two hours helps redistribute pressure, reduces the risk of pressure ulcers, and maintains skin integrity.

Potential Condition:

D. Rheumatoid arthritis: The client's clinical presentation, including bilateral joint pain and stiffness, positive rheumatoid factor, positive antinuclear antibody test, elevated erythrocyte sedimentation rate (ESR), and soft tissue swelling with marginal erosions on hand X-rays, is consistent with rheumatoid arthritis (RA). RA is a chronic autoimmune disease characterized by inflammation of the synovial joints, leading to joint damage, pain, and functional impairment.

Parameters to Monitor:

C. Pain: Monitoring pain is essential in rheumatoid arthritis management to assess the effectiveness of pain management interventions and adjust treatment accordingly. Pain assessment tools, such as numerical rating scales or visual analog scales, help quantify pain intensity and guide pain management strategies.

D. Skin breakdown: Rheumatoid arthritis can limit mobility and predispose individuals to prolonged immobility, increasing the risk of pressure injuries. Monitoring for signs of skin breakdown, such as erythema, blanchable or non-blanchable skin changes, and skin integrity over bony prominences, helps prevent pressure ulcers and facilitates early intervention if skin breakdown occurs. Regularly turning the client, maintaining proper positioning, and providing adequate support surfaces are essential to prevent pressure injuries.

Exhibits

The nurse is implementing solutions to provide care.

Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.

The nurse determines that the client's is still having an adverse reaction resulting in symptoms of dropdown
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 and dropdown

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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.

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Naxlex Comprehensive Predictor Exams

The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mcg/2.4 mL". How many ml. should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["0.2"]

Explanation

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

A postpartum client who is bottle-feeding develops breast engorgement. Which is the best recommendation for the nurse to provide this client?

The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?

The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mcg/2.4 mL". How many ml. should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

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.