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.

A Allergies

B Circulation

C Neurological status

D Ventilation

E Current medications

F Exposure

Answer and Explanation

Correct Answer : B,D,E

A. Allergies
Allergies are important to know but are not part of the primary survey. The primary survey focuses on immediate life threats, such as airway, breathing, and circulation, rather than detailed background information.
B. Circulation
Assessment of circulation is critical in the primary survey to identify and manage life-threatening conditions such as shock or severe bleeding. It includes evaluating blood pressure, heart rate, and peripheral pulses to assess the effectiveness of the cardiovascular system.
C. Neurological status
While neurological status is important, it is part of a secondary survey rather than the primary survey. The primary survey focuses on immediate life-threatening conditions, while the neurological status is assessed more thoroughly in the secondary survey.
D. Ventilation
Assessing ventilation is a crucial part of the primary survey. This involves checking the client's breathing rate, depth, and effectiveness to ensure adequate oxygenation and addressing any immediate respiratory distress.
E. Current medications
Knowing current medications is important for overall care but is not part of the primary survey. The primary survey addresses life-threatening conditions rather than details of medication history.
F. Exposure
Exposure is part of the primary survey, ensuring that the client is completely exposed for a thorough assessment while protecting their privacy and warmth. It involves checking for hidden injuries and ensuring the client’s environment is safe.

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Correct Answer is A

Explanation

Rationale:
A. Furosemide is a loop diuretic that helps to lower potassium levels, making it appropriate for a client with hyperkalemia (potassium level of 5.3 mEq/L).
B. Potassium iodide would further increase potassium levels, which is contraindicated in this situation.
C. Digoxin does not directly affect potassium levels and could be dangerous in the context of hyperkalemia.
D. Lisinopril is an ACE inhibitor that can increase potassium levels, which would not be appropriate for this client.

A. Pernicious anemia B. Prostate enlargement C. Dehydration D. Bladder infection

Correct Answer is D

Explanation

A. Pernicious anemia is a condition related to vitamin B12 deficiency and does not typically cause blood-tinged urine.
B. Prostate enlargement (benign prostatic hyperplasia) can cause urinary symptoms like hesitancy and frequency but does not directly cause blood-tinged urine.
C. Dehydration can lead to concentrated urine and urinary tract irritation but does not typically cause blood-tinged urine.
D. Blood-tinged urine in a client with an indwelling urinary catheter is concerning for a bladder infection, especially if accompanied by other signs like fever or foul odor.

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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.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client whose serum potassium level is 5.3 mEq/L. Which of the following scheduled medications should the nurse plan to administer?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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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.

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.