Exhibits

Following the fluid bolus, the client is more awake and able to answer questions. What questions are appropriate for the secondary survey? Select all that apply.

Do you take any medications?

What happened before you fell?

What was your last meal?

Is it possible that you are pregnant?

Do you live with anyone?

Are you fully insured?

Answer and Explanation

Correct Answer : A,B,C,D,E

-   A) Knowing the medications the patient takes is crucial for understanding her medical history and any potential interactions with treatments that may be administered.

-   B) Understanding the events leading up to the fall can help in assessing the cause and potential injuries sustained, which is important for her current and future treatment plans.

-   C) Information about the last meal is important for anesthesia considerations, in case surgery is required, and for understanding the patient's nutritional status.
-   D) Knowing if the patient is pregnant is vital as it influences the management of her care and the urgency of certain tests, as well as the avoidance of potential harm to the fetus.
-   E) Information about cohabitants can be useful for social support and may also provide additional information about the circumstances leading to the injury.
-   F) While insurance status is a practical consideration, it is not clinically relevant to the secondary survey and immediate care of the patient. Therefore, it is not an appropriate question at this stage.

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Correct Answer is B

Explanation

A. Oxygen is less toxic when it is humidified with a hydration source. While humidification can prevent drying of the respiratory mucosa, it does not directly relate to the principle of avoiding high levels of oxygen for extended periods.
B. Avoid administration of oxygen at high levels for extended periods. This is the correct principle. Prolonged exposure to high levels of oxygen can lead to oxygen toxicity, which can cause lung damage. Oxygen therapy should be titrated to maintain adequate oxygenation without exposing the patient to excessive oxygen levels.
C. Increase oxygen rate during sleep to compensate for slower respiratory rate. This statement is incorrect. Oxygen therapy should be adjusted based on the patient's oxygen saturation levels and respiratory status, not solely on sleep patterns.
D. Taking a sedative at bedtime slows respiratory rate, which decreases oxygen needs. While sedatives can depress respiratory rate, leading to decreased oxygen needs, this is not a general principle of oxygen administration. Oxygen therapy should be based on the patient's oxygenation needs rather than medications they are taking.

A. Neurological status B. Circulation C. Current medications D. Allergies E. Exposure F. Ventilation

Correct Answer is ["A","B","E"]

Explanation

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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Exhibits Following the fluid bolus, the client is more awake and able to answer questions. What questions are appropriate for the secondary survey? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Oxygen at 5 L/minute per nasal cannula is being administered to a 10-year-old child with pneumonia. When planning care for this child, which principle of oxygen administration should the nurse consider?

Correct Answer is B

Explanation

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.

Correct Answer is ["A","B","E"]

Explanation

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Exhibits

Following the fluid bolus, the client is more awake and able to answer questions. What questions are appropriate for the secondary survey? Select all that apply.