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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Fluid volume deficit. Gastroenteritis, characterized by fever, chills, anorexia, and diarrhea, can lead to significant fluid loss, especially in an older adult who may already have compromised fluid balance due to other factors such as stroke-related immobility. Fluid volume deficit is a critical problem that requires immediate attention to prevent complications such as hypovolemic shock.
B. Bowel incontinence. While bowel incontinence is a concern, it is not as immediately life- threatening as fluid volume deficit.
C. Caregiver role strain. While important for the client's overall well-being, caregiver role strain is a secondary concern compared to the client's physiological needs.
D. Impaired bed mobility. Impaired bed mobility is a long-term issue that requires attention but is not as urgent as addressing the immediate physiological needs of fluid volume deficit.
Correct Answer is A
Explanation
A. Administer oxygen via face mask. The decrease in fetal heart rate after contractions indicates possible fetal distress. Administering oxygen to the mother can increase oxygen delivery to the fetus, potentially improving fetal oxygenation and alleviating distress.
B. Apply an Internal fetal heart monitor. While continuous monitoring is important, the first priority is to address the immediate fetal distress. Monitoring alone will not address the issue.
C. Notify the healthcare provider. Notifying the provider is important, but addressing the immediate fetal distress takes priority.
D. Use a vibroacoustic stimulator. Vibroacoustic stimulation can be used to assess fetal well- being, but it does not address the underlying fetal distress, which is the priority.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.