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?
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Every 5 minutes for 30 minutes is crucial after paracentesis to closely monitor for signs of hypovolemia, such as a sudden drop in blood pressure. After this initial intensive monitoring period, the frequency can be reduced to every 4 hours to assess for any delayed effects or complications.
B. Every 5 minutes for one hour is a shorter duration of monitoring compared to option A and
may not provide adequate time to detect and respond to any significant changes in blood pressure that could occur after paracentesis, especially considering the volume of fluid removed.
C. Every 15 minutes for one hour, then every 1 hour for 2 hours provides frequent monitoring
initially, but the interval between assessments is too long after the first hour, potentially missing early signs of complications such as hypovolemia.
D. Every 1 hour for 2 hours does not provide sufficient frequency of monitoring, especially during the critical immediate post-paracentesis period when rapid changes in blood pressure can occur. This schedule may delay the detection and management of complications.
Correct Answer is D
Explanation
A. Plan to observe the secured IV site after the insertion procedure.
This is a proactive step, but it does not address the immediate need to correct the new nurse’s choice of dressing.
B. Remind the nurse to tape the gauze dressing securely in place.
While securing the dressing is important, it is not the best practice to use a gauze dressing for IV sites as it obscures the view of the insertion site.
C. Confirm that the nurse has gathered the necessary supplies.
Confirming supplies is important, but this does not address the incorrect dressing choice.
D. Instruct the nurse to use a transparent dressing over the site.
This is the correct answer because a transparent dressing allows for continuous visual inspection of the IV site for signs of infection or infiltration, which is crucial for patient safety.
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