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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 []

Explanation

Hypocalcemia:

- Condition: Hypocalcemia is a condition characterized by low levels of calcium in the blood. In newborns and infants, this can occur due to inadequate intake or absorption of calcium, and it can manifest as seizures.

- Rationale: The infant was fed cow's milk, which is not recommended for infants under one year old and can interfere with calcium absorption, possibly leading to hypocalcemia. Seizures can be a symptom of severe hypocalcemia.

Actions to Take:

1. Administer oral calcium:

- Rationale: Direct administration of calcium helps to quickly elevate calcium levels in the blood, addressing the immediate cause of the seizures.
2. Educate the mother on nutrition needs:

- Rationale: It's important to educate the mother on the appropriate nutritional needs for an

infant, emphasizing the importance of breastfeeding or formula feeding instead of cow's milk, to prevent recurrence.

Parameters to Monitor:

1. Electrocardiogram:

- Rationale: Monitoring the ECG is crucial as hypocalcemia can cause cardiac arrhythmias, and the ECG can provide real-time information about the infant's cardiac status.
2. Oxygen saturation:

- Rationale: Monitoring oxygen saturation ensures that the infant maintains adequate oxygenation, especially after a seizure and during recovery, to detect any respiratory complications early.

Correct Answer is ["1.8"]

Explanation

Steps to solve:

Convert the client's weight from pounds to kilograms:
- Weight (kg) = Weight (pounds) / 2.20462
- Weight (kg) = 132 pounds / 2.20462 ≈ 59.87 kg (round to nearest tenth for medication calculation)
Calculate the total dantrolene dosage based on the prescribed dosage per kilogram:

- Dosage (mg) = Weight (kg) x Dosage per kg
- Dosage (mg) = 59.87 kg x 1.5 mg/kg
- Dosage (mg) ≈ 89.8 (round to nearest tenth)

Determine the concentration of dantrolene after reconstitution:

Concentration = 50 mg/mL (given on the vial label)

Calculate the volume of the solution to administer:

- Volume (mL) = Dosage (mg) / Concentration (mg/mL)
- Volume (mL) = 89.8 mg / 50 mg/mL
- Volume (mL) ≈ 1.79 mL (round to one decimal place)= 1.8mL

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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

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

Correct Answer is ["1.8"]

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.