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","C","E","F"]

Explanation

A. The client has not received pneumococcal vaccine, which increases susceptibility to pneumococcal pneumonia.
B. The client is oriented to time place and person which is normal.
C. The client has not received influenza vaccine, which increases susceptibility to pneumococcal pneumonia.
D. The client has no significant health history other than the primary concern.
E. The client's fluid intake seems to be reduced, as indicated by their decreased urination and reports of not drinking much water due to a sore throat, which can contribute to the risk of infection.
F. Being 70 years old increases susceptibility to respiratory infections like pneumonia.
G. No history of smoking reduces risk compared to smokers, but is still a risk factor in pneumonia development.

A. Difficulty moving the upper extremities B. Difficulty hearing some types of sounds C. Stiffness in the lower extremities D. A reddened area over the sacrum

Correct Answer is D

Explanation

A. Difficulty moving the upper extremities may be a result of the stroke but is not a direct complication of immobility.
B. Difficulty hearing some types of sounds is not a typical complication of immobility.
C. Stiffness in the lower extremities can occur but is less urgent than skin breakdown.
D. A reddened area over the sacrum indicates pressure injury, a common and serious complication of immobility that requires immediate attention.

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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 an emergency department (ED) is admitting a client. Exhibits Select 4 findings in the client's medical record that place them at risk for pneumonia.

Correct Answer is ["A","C","E","F"]

Explanation

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?

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.