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 D

Explanation

Rationale:
A. Auscultating bowel sounds for 3 to 5 minutes is appropriate if sounds are not initially heard.
B. Clamping the NG tube prevents false bowel sounds from the tube.
C. Performing auscultation between meals ensures accurate assessment of bowel sounds.
D. Palpating the abdomen prior to auscultation can alter bowel sounds, making it important to auscultate before palpation.

A. Elevated ST segment B. Abnormally prominent U wave C. Wide QRS D. Inverted P wave

Correct Answer is B

Explanation

Rationale:
A. Elevated ST segment is typically associated with myocardial infarction or pericarditis, not hypokalemia.
B. An abnormally prominent U wave is a classic sign of hypokalemia on an EKG.
C. Wide QRS complex can be seen with severe hyperkalemia or other conditions affecting ventricular conduction.
D. Inverted P wave is not associated with hypokalemia; it is more often related to atrial conduction abnormalities or ectopic atrial rhythm.

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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 charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?

Correct Answer is D

Explanation

A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?

Correct Answer is B

Explanation

A nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm?

A client who has Type 2 diabetes mellitus asks the nurse, "Why did I develop diabetes?" Which of the following responses should the nurse make?

A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene?

A nurse is teaching a client about foods that are included on a clear liquid diet. Which of the following food choices made by the client indicates the need for further teaching?

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 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 planning care for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following manifestations is most appropriate for the nurse to monitor?

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.