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The nurse inspects the airway and finds no visible trauma, and the airway appears to be patent.
What other assessment items are included in the primary survey? Select all that apply.

Ventilation

Neurological status

Exposure

Current medications

Allergies

Circulation

Answer and Explanation

Correct Answer : A,B,C,F

The correct answer is A. Ventilation, B. Neurological status, C. Exposure, F. Circulation.

Choice A: Ventilation Ventilation is a crucial part of the primary survey in trauma assessment. It involves assessing the patient’s respiratory rate and effort, use of accessory muscles, cyanosis, and chest wall movement. The normal respiratory rate for adults is between 12-20 breaths per minute.

Choice B: Neurological status Neurological status is another vital component of the primary survey. It often involves assessing the patient’s level of consciousness, often using tools like the Glasgow Coma Scale (GCS). The GCS score can range from 3 (completely unresponsive) to 15 (responsive).

Choice C: Exposure Exposure involves removing the patient’s clothing to check for any hidden injuries. It’s an essential step in trauma assessment, but there’s no “normal range” for this as it’s a process rather than a measurable variable.

Choice D: Current medications While knowing a patient’s current medications is important in managing their care, it’s not typically part of the primary survey in trauma assessment. This information is usually gathered during the secondary survey.

Choice E: Allergies Like current medications, information about allergies is also crucial in managing patient care, but it’s not part of the primary survey. This information is usually collected during the secondary survey.

Choice F: Circulation Circulation is a critical part of the primary survey. It involves checking the patient’s heart rate, blood pressure, capillary refill time, and looking for any signs of external bleeding. The normal resting heart rate can range between 60-99 beats per minute.

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Correct Answer is C

Explanation

Choice A rationale
Comparing muscle strength bilaterally is important in assessing overall physical health and detecting any potential neuromuscular disorders. However, in the context of a client with a history of heart failure and elevated potassium levels, this would not be the most critical intervention. High potassium levels can lead to hyperkalemia, which can cause serious heart rhythm disturbances.
Choice B rationale
Observing the color and amount of urine can provide valuable information about the client’s hydration status and kidney function. In the case of heart failure, monitoring urine output can help assess the effectiveness of diuretic therapy and the progression of the disease. However, it is not the most immediate concern given the client’s high potassium levels.
Choice C rationale

Determining the apical pulse rate and rhythm is the most important intervention in this scenario. A serum potassium level of 6.2 mEq/L is higher than the normal range (3.5-5.0 mEq/L) and can cause life-threatening heart rhythm abnormalities. Therefore, the nurse should prioritize assessing the client’s heart rhythm to detect any abnormalities caused by this electrolyte imbalance.
Choice D rationale
Assessing the strength of deep tendon reflexes can help identify changes in neuromuscular function and is often used in neurological assessments. However, it is not the most critical intervention in the context of elevated potassium levels and heart failure.

A. Mix the dextrose in a 50 mL piggyback for a total volume of 100 mL. B. Dilute the dextrose in one liter of 0.9% normal saline solution. C. Request the pharmacist to add the dextrose to a total parenteral nutrition (TPN) solution. D. Administer the undiluted dextrose slowly through the currently infusing IV. .

Correct Answer is D

Explanation

Choice A rationale
Mixing the dextrose in a 50 mL piggyback for a total volume of 100 mL is not the appropriate method for administering the medication. This would dilute the dextrose, reducing its concentration and potentially making it less effective.
Choice B rationale
Diluting the dextrose in one liter of 0.9% normal saline solution is not the appropriate method for administering the medication. This would significantly dilute the dextrose, reducing its concentration and potentially making it less effective.
Choice C rationale
Requesting the pharmacist to add the dextrose to a total parenteral nutrition (TPN) solution is not the appropriate method for administering the medication. While dextrose is often a component of TPN solutions, in this case, the patient requires a concentrated dose of dextrose to treat insulin shock.

Choice D rationale
This is the correct answer. Administering the undiluted dextrose slowly through the currently infusing IV is the appropriate method for administering the medication. This allows for the rapid administration of a concentrated dose of glucose, which is necessary to quickly raise the patient’s blood glucose level in the case of insulin shock.

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The nurse inspects the airway and finds 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

Correct Answer is C

Explanation

The nurse is preparing a 50 mL dose of 50% dextrose IV for a patient with insulin shock. What is the appropriate method for administering the medication?

Correct Answer is D

Explanation

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The nurse inspects the airway and finds no visible trauma, and the airway appears to be patent.
What other assessment items are included in the primary survey? Select all that apply.