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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.

Neurological status

Circulation

Current medications

Allergies

Exposure

Ventilation

Answer and Explanation

Correct Answer : A,B,E

A. Neurological status: Assessing the neurological status is crucial in the primary survey to

determine the client's level of consciousness, pupil reactions, and response to stimuli. This helps in identifying any potential brain injury or neurological deficits resulting from the fall.

B. Circulation: Evaluating circulation involves assessing the client's heart rate, blood pressure, and peripheral perfusion. In this scenario, the client's heart rate and blood pressure are provided in the nurse's notes, indicating the need to assess circulation as part of the primary survey.

C. Current medications: While important for the overall assessment and care of the client, assessing current medications is typically part of the secondary survey rather than the primary survey. The primary survey focuses on immediate life-threatening conditions.

D. Allergies: While allergies are essential information for the client's overall care, they are typically addressed during the secondary survey or during the history-taking process rather than as part of the primary survey.

E. Exposure: Assessing exposure involves ensuring the client is adequately covered and protected from environmental factors, especially in trauma situations where there may be significant blood loss or risk of hypothermia. This includes removing clothing to assess for additional injuries or bleeding.

F. Ventilation: While ventilation is crucial for assessing the client's respiratory status, including respiratory rate and effort, it is typically part of the primary survey rather than the primary survey itself. Assessing ventilation helps determine if the client is adequately breathing and oxygenating.

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Correct Answer is C

Explanation

A. Cover client with cooling blanket.
This could help manage the fever but is not the highest priority in the context of acute adrenal crisis.

B. Obtain an analgesic prescription.
Pain management is important, but it is not the immediate priority in a life-threatening adrenal crisis.

C. Infuse an intravenous fluid bolus.
This is the correct answer because the client is experiencing hypotension (low blood pressure), which is critical in an acute adrenal crisis. IV fluids are essential to restore blood pressure and perfusion.

D. Administer PRN oral antipyretic.
Managing the fever is important, but not the first priority. The client’s hemodynamic instability needs to be addressed immediately.

A. Shaking is lessened B. Client is no longer flushed C. No longer itching D. Anxiety has decreased E. Skin warm and dry F. Heart rate 62 beats/minute, blood pressure 130/72 mm Hg G. No chest pain noted H. Respirations are even and unlabored I. Drowsy

Correct Answer is ["A","B","C","D","E","F","G","H","I"]

Explanation

Shaking is lessened: Shaking or tremors can be a manifestation of the body's response to stress or discomfort. A decrease in shaking suggests that the client's physiological response is returning to normal, indicating improvement.
Client is no longer flushed: Flushing, or the reddening of the skin, can occur as a result of vasodilation during an allergic reaction or due to increased blood flow associated with elevated body temperature. The absence of flushing suggests that the body's inflammatory response has subsided, indicating resolution of the adverse reaction.
No longer itching: Itching, or pruritus, is a common symptom of allergic reactions mediated by histamine release. The cessation of itching suggests that the inflammatory mediators responsible for the itching response have been cleared from the body, indicating resolution of the allergic reaction.
Anxiety has decreased: Anxiety can be a psychological response to physical discomfort or distress. A decrease in anxiety levels suggests that the client is experiencing less discomfort and is psychologically improving, which can be indicative of recovery from the adverse drug reaction.
Skin warm and dry: Warm and dry skin is a sign of normal thermoregulation and hydration status. The presence of warm and dry skin suggests that the client's body temperature andhydration levels are within normal limits, indicating physiological stability and recovery from the adverse drug reaction.
Heart rate 62 beats/minute, blood pressure 130/72 mm Hg: Vital signs within normal limits, including a heart rate and blood pressure within the client's baseline range, indicate stability of cardiovascular function and resolution of any hemodynamic instability associated with the adverse drug reaction.
No chest pain noted: Chest pain can be indicative of cardiovascular compromise or ischemia. The absence of chest pain suggests that the client's cardiovascular function has normalized, further supporting recovery from the adverse drug reaction.
Respirations are even and unlabored: Even and unlabored respirations indicate normal respiratory function and adequate gas exchange. The absence of respiratory distress or effort suggests resolution of any respiratory complications associated with the adverse drug reaction.
Drowsy: Drowsiness can be a side effect of medications such as antihistamines or a natural response to the body's recovery process. While drowsiness may persist for a period after the adverse drug reaction resolves, its presence alongside other signs of improvement suggests that the client's body is returning to a state of equilibrium.

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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

Correct Answer is C

Explanation

Correct Answer is ["A","B","C","D","E","F","G","H","I"]

Explanation

Exhibits Following the fluid bolus, the client is more awake and able to answer questions. What questions are appropriate for the secondary survey? Select all that apply.

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An intravenous (IV) antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. Which schedule is best for administering this prescription?

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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.