The nurse understands the primary assessment for a patient following a major trauma:

includes the head-to-toe anterior and posterior assessment

focuses on the ABCDE's to identify life threating problems

includes the use of a standard pain scale and past medical/surgical history

consists of analyzing the results of the diagnostic testing

Answer and Explanation

The Correct Answer is B

A) Includes the head-to-toe anterior and posterior assessment:
While a head-to-toe physical assessment is important in trauma care, it is not the first priority. The primary assessment focuses on immediate life-threatening conditions, and the head-to-toe assessment would come after the initial stabilization of the patient's airway, breathing, circulation, and disability. A comprehensive physical examination is crucial but secondary to addressing urgent life threats.

B) Focuses on the ABCDE's to identify life-threatening problems:
The ABCDE's (Airway, Breathing, Circulation, Disability, Exposure) are the primary framework for assessing and stabilizing a trauma patient. This approach is used to identify and prioritize life-threatening problems. It ensures that the most critical issues, such as airway obstruction, respiratory failure, shock, and neurological deficits, are addressed first. This protocol is the gold standard in trauma care and is the most appropriate initial assessment in major trauma.

C) Includes the use of a standard pain scale and past medical/surgical history:
While it is important to assess pain and gather a medical history in the trauma patient, these are secondary considerations after addressing immediate threats to life. Pain management and obtaining a full history are crucial, but they are not as urgent as addressing airway, breathing, and circulation issues. These should be part of a more detailed secondary assessment once the patient is stable.

D) Consists of analyzing the results of the diagnostic testing:
Diagnostic testing, such as imaging studies and lab work, are important but are not the first priority. The primary assessment should focus on the ABCDE's. Diagnostic results are typically analyzed after the patient is stabilized, as they provide additional information but do not address immediate survival needs.

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Correct Answer is ["D","E"]

Explanation

A) Pneumonia: Pneumonia is a direct cause of ARDS, as it involves direct inflammation and infection of the lung tissue, leading to impaired oxygen exchange and damage to the alveolar-capillary membrane. It results in fluid accumulation in the lungs, which is a key characteristic of ARDS.

B) Drowning: Drowning is another direct cause of ARDS. It involves the aspiration of water into the lungs, which directly damages lung tissue, causing pulmonary edema and impaired oxygenation.

C) Aspiration: Aspiration of food, liquid, or vomit into the lungs is also a direct cause of ARDS. The aspirated material can lead to chemical pneumonia, bacterial infection, and inflammation of the lungs, which in turn causes ARDS.

D) Sepsis: Sepsis is an indirect cause of ARDS. It can lead to widespread inflammation throughout the body, including the lungs, through the release of inflammatory mediators (cytokines, interleukins, etc.). These systemic inflammatory responses can increase capillary permeability in the lungs, causing fluid to leak into the alveoli, which leads to ARDS.

E) Blood Transfusion: Blood transfusion, particularly when associated with transfusion-related acute lung injury (TRALI), is an indirect cause of ARDS. TRALI is a serious complication that can result from receiving blood products, where the transfused blood causes an immune response leading to pulmonary damage. It indirectly triggers inflammation and fluid buildup in the lungs, contributing to ARDS.

Correct Answer is ["12"]

Explanation

Given:

Ordered dose of Heparin: 20 units/kg

Patient weight: 132 lbs

Concentration of Heparin: 25,000 units/250 mL (100 units/mL)

Step 1: Convert patient weight from pounds to kilograms:

1 pound (lb) = 0.453592 kilograms (kg)

Patient weight in kg = 132 lbs x 0.453592 kg/lb = 59.87424 kg

Step 2: Calculate the total dose of Heparin:

Total dose (units) = Ordered dose (units/kg) x Patient weight (kg)

Total dose (units) = 20 units/kg x 59.87424 kg

Total dose (units) = 1197.4848 units

Step 3: Calculate the volume to be administered:

Volume (mL) = Total dose (units) / Concentration (units/mL)

Volume (mL) = 1197.4848 units / 100 units/mL

Volume (mL) = 11.974848 mL

Step 4: Round to the nearest whole number:

Volume (mL) ≈ 12 mL

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The nurse understands the primary assessment for a patient following a major trauma:

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Naxlex Comprehensive Predictor Exams

What does the nurse identify as INDIRECT cause of acute respiratory distress syndrome (ARDS) SELECT ALL THAT APPLY

Correct Answer is ["D","E"]

Explanation

A patient is to receive a bolus of Heparin 20 units/kg. The patient weighs 132 lbs. The medication is supplied as 25,000 units/250 mL. How many mL will the nurse give? (round to the nearest whole number)

Correct Answer is ["12"]

Explanation

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