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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 ["A","D"]

Explanation

Choice A rationale
A chest x-ray is a critical diagnostic tool for a patient presenting with flu-like symptoms, fever, chest congestion, and increased breathing difficulties. It can help identify conditions such as pneumonia or other lung diseases, which could be causing the patient’s symptoms.
Choice B rationale
While hydration is important, running a 0.9% sodium chloride IV infusion at 150 mL/hour is not the most immediate need for this patient. The patient’s symptoms are primarily respiratory, and there is no indication of dehydration.
Choice C rationale
A sputum culture could be useful for diagnosing bacterial infections of the respiratory tract. However, it is not the most immediate need for this patient, as the results of a culture test can take time to come back.
Choice D rationale
This is the correct answer. Given the patient’s increased breathing difficulties, starting oxygen therapy can help improve the patient’s oxygen levels and ease their breathing.
Choice E rationale

Starting a peripheral IV might be necessary for administering medications or fluids, but it is not the most immediate need in this scenario.
Choice F rationale
While controlling the patient’s fever is important, it is not as immediate a need as performing a chest x-ray and starting oxygen therapy.

A. Chills and fever. B. Lack of appetite. C. Swollen hands. D. Headache. E. Blurred vision. F. Frequent urination.

Correct Answer is ["C","D","E"]

Explanation

Choice A rationale
Chills and fever are not typically associated with preeclampsia. They are more commonly seen in infections.
Choice B rationale
Lack of appetite is a non-specific symptom and can be associated with many conditions, but it is not a key indicator of preeclampsia.
Choice C rationale
Swollen hands can be a symptom of preeclampsia. This condition can cause sudden weight gain and swelling (edema), particularly in your face and hands.

Choice D rationale
Headaches are a common symptom of preeclampsia. They are often severe and may be accompanied by changes in vision.
Choice E rationale
Blurred vision is a symptom of preeclampsia. Other vision changes, such as sensitivity to light or temporary loss of vision, can also occur.
Choice F rationale
Frequent urination is not typically associated with preeclampsia. It is a common symptom in early and late pregnancy due to the growing uterus pressing on the bladder.

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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.

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","D"]

Explanation

The nurse is educating a first-time pregnant woman about preeclampsia. Which symptoms are indicators of preeclampsia and should be reported to the healthcare provider? Select all that apply.

Correct Answer is ["C","D","E"]

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.