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

Ventilation

Neurological status

Exposure

Current medications

Allergies

Circulation

Answer and Explanation

Correct Answer : A,B,C,F

The correct answer is A. Ventilation, B. Neurological status, C. Exposure, F. Circulation.

Choice A: Ventilation Ventilation is a crucial part of the primary survey in trauma assessment. It involves assessing the patient’s respiratory rate and effort, use of accessory muscles, cyanosis, and chest wall movement. The normal respiratory rate for adults is between 12-20 breaths per minute.

Choice B: Neurological status Neurological status is another vital component of the primary survey. It often involves assessing the patient’s level of consciousness, often using tools like the Glasgow Coma Scale (GCS). The GCS score can range from 3 (completely unresponsive) to 15 (responsive).

Choice C: Exposure Exposure involves removing the patient’s clothing to check for any hidden injuries. It’s an essential step in trauma assessment, but there’s no “normal range” for this as it’s a process rather than a measurable variable.

Choice D: Current medications While knowing a patient’s current medications is important in managing their care, it’s not typically part of the primary survey in trauma assessment. This information is usually gathered during the secondary survey.

Choice E: Allergies Like current medications, information about allergies is also crucial in managing patient care, but it’s not part of the primary survey. This information is usually collected during the secondary survey.

Choice F: Circulation Circulation is a critical part of the primary survey. It involves checking the patient’s heart rate, blood pressure, capillary refill time, and looking for any signs of external bleeding. The normal resting heart rate can range between 60-99 beats per minute.

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Correct Answer is ["100"]

Explanation

Step 1: The child is receiving gentamicin 60 mg every 8 hours IV, which is to be infused over 30 minutes. The medication is delivered by the pharmacy diluted in a 50 ml bag of saline.

Step 2: We need to find the infusion pump’s regulation in mL/hour.

Step 3: Since the medication is to be infused over 30 minutes, we convert this to hours by dividing by 60. So, 30 minutes is 0.5 hours.

Step 4: The rate of infusion is then the total volume (50 mL) divided by the time in hours (0.5 hours).

Step 5: So, the infusion pump’s regulation is (50 mL ÷ 0.5 hours) = 100 mL/hour.

A. Lamb’s wool B. Sterile water C. Tape D. Suction canister E. Humidifier bottle F. Nasal cannula G. Flowmeter

Correct Answer is ["B","C","D","E","F","G"]

Explanation

Choice A rationale
Lamb’s wool is typically used for padding to prevent pressure sores and does not directly relate to the administration of oxygen therapy. Therefore, it is not necessary when a patient is put on oxygen.
Choice B rationale
Sterile water is used in oxygen therapy to provide humidification, which prevents the drying and irritation of the respiratory mucosa. Therefore, it is necessary when a patient is put on oxygen.
Choice C rationale
Tape can be used to secure the oxygen delivery device, such as a nasal cannula, to the patient’s face. Therefore, it is necessary when a patient is put on oxygen.
Choice D rationale
A suction canister is used to collect respiratory secretions during suctioning procedures, which may be necessary for patients with excessive secretions or difficulty clearing secretions.
Therefore, it is necessary when a patient is put on oxygen.
Choice E rationale
A humidifier bottle is used in oxygen therapy to provide humidification, which prevents the drying and irritation of the respiratory mucosa. Therefore, it is necessary when a patient is put on oxygen.

Choice F rationale
A nasal cannula is a device used to deliver supplemental oxygen to a patient who needs oxygen therapy. Therefore, it is necessary when a patient is put on oxygen.
Choice G rationale
A flowmeter is used in oxygen therapy to control the rate of oxygen flow to the patient. Therefore, it is necessary when a patient is put on oxygen.

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The nurse inspects the airway and finds 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 ["100"]

Explanation

Correct Answer is ["B","C","D","E","F","G"]

Explanation

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