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 B

Explanation

Rationale:
A. The float nurse may not be familiar with discharge planning specific to long-term care facilities.
B. A nurse from the PACU is highly experienced with postoperative care and monitoring of clients with chest tubes, making this the most appropriate assignment.
C. Teaching about insulin self-administration requires specific education techniques which the float nurse might not be most familiar with.
D. Teaching for cardiac rehabilitation involves specialized knowledge that might be outside the float nurse’s expertise.

A. Sleep on a soft mattress. B. Avoid prolonged sitting. C. Apply heat for 10 min every hour. D. Sleep in a side-lying position with flexed knees. E. Try padded shoe insoles.

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

Explanation

Rationale:
A. Sleeping on a firm mattress is generally recommended to support the spine and prevent back strain.
B. Avoiding prolonged sitting helps reduce pressure on the lower back and can prevent back pain.
C. Applying heat intermittently can provide temporary relief but does not prevent back strain.
D. Sleeping in a side-lying position with knees flexed helps maintain natural spinal curvature and reduces strain on the back.
E. Padded shoe insoles may provide comfort. Proper arch support can improve posture and reduce stress on the lower back.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse should recognize that the float nurse is most qualified to care for which of the following clients?

Correct Answer is B

Explanation

A nurse is educating coworkers about how to minimize back strain and avoid repeated episodes of low back pain. Which of the following strategies should the nurse include? (Select all that apply.)

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

Explanation

A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

A nurse is caring for a client who ingested a poison and is now experiencing a seizure. Which of the following is the priority action the nurse should take?

A patient with hypotension and an elevated temperature after working outside on a hot day is treated in the emergency department (ED). Which patient statement indicates to the nurse that discharge teaching has been effective?

A nurse is teaching a class on health promotion and illness prevention. The nurse should include that which of the following is an example of secondary prevention?

A nurse is teaching a client who has hypertension and a new prescription for atenolol. Which of the following findings should the nurse include as adverse effects of this medication?

A nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching?

A nurse is caring for a client who has a fractured ulna and a new prescription for cyclobenzaprine. Before administering, which of the following explanations should the nurse provide to explain the purpose of the medication?

A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products?

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.