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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. Offer the client oral fluids. Offering fluids is important but is not directly related to turning the client or managing the urinary catheter.
B. Assess the breath sounds. Assessing breath sounds is beyond the scope of practice for a UAP.

C. Empty the urinary drainage bag. This action helps maintain catheter function and reduces the risk of infection by preventing urine from backing up in the bladder.
D. Feed the client a snack. Feeding the client is important but is not related to turning the client or managing the urinary catheter.

A. Erythrocytes, hemoglobin, and hematocrit. B. Serum potassium, calcium, and phosphorus. C. Blood pressure, heart rate, and temperature. D. Leukocytes, neutrophils, and thyroxine.

Correct Answer is B

Explanation

A. While monitoring erythrocytes, hemoglobin, and hematocrit is important in clients with ESRD due to the risk of anemia associated with kidney dysfunction, it is not the primary focus of monitoring for ESRD.

B. Clients with ESRD often experience electrolyte imbalances, including hyperkalemia (high potassium), hypocalcemia (low calcium), and hyperphosphatemia (high phosphorus). Monitoring these electrolyte levels is crucial to prevent complications such as cardiac arrhythmias, bone
disease, and soft tissue calcifications.

C. While blood pressure, heart rate, and temperature are essential vital signs to monitor in all clients, they are not specific laboratory tests for monitoring ESRD. However, blood pressure monitoring is particularly important in ESRD due to the increased risk of hypertension and its associated complications.

D. Monitoring leukocytes, neutrophils, and thyroxine levels is not typically a primary concern in clients with ESRD. Leukocyte and neutrophil levels may be monitored to assess for signs of infection, but they are not specific to ESRD. Thyroxine levels are typically monitored in clients with thyroid disorders, not ESRD.

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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.

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Naxlex Comprehensive Predictor Exams

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. Which additional action should the nurse instruct the UAP to take each time the client is turned?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. What intervention(s) should the nurse include in this client's plan of care? Select all that apply.

Exhibits The nurse should place the client in a position to promote

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Prior to insertion of an indwelling urinary catheter, which client information is most important for the nurse to obtain?

Exhibits Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.

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.