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

A. Metabolic alkalosis is characterized by an elevated HCO3 and pH.
B. Metabolic acidosis is indicated by a low HCO3 (18 mEq/L) and a low pH (7.30). The low PaCO2 is a compensatory response.
C. Respiratory acidosis is indicated by an elevated PaCO2 and a low pH.
D. Respiratory alkalosis is indicated by a low PaCO2 and an elevated pH.

A. Erythrocyte sedimentation rate (ESR) B. Antinuclear antibody (ANA) C. Rheumatoid factor (RF) D. White blood cell (WBC) count

Correct Answer is A

Explanation

A. The erythrocyte sedimentation rate (ESR) is a marker of inflammation and is used to monitor the effectiveness of anti-inflammatory treatments such as aspirin in clients with rheumatoid arthritis.
B. Antinuclear antibody (ANA) is used to diagnose autoimmune diseases but is not typically monitored for the effectiveness of aspirin therapy in RA.
C. Rheumatoid factor (RF) is used for the diagnosis of RA, but it does not change significantly with treatment.
D. White blood cell (WBC) count is not a specific marker for monitoring the effectiveness of aspirin in treating RA.

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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 is caring for a client who has the following arterial blood gas results: HCO, 18 mEq, PaCO2 28 mm Hg and pH 7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances?

Correct Answer is B

Explanation

A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication?

Correct Answer is A

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.