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    HESI RN EXIT 3 PROCTORED EXAMQuestion 112
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    HESI RN EXIT 3 PROCTORED EXAM
    Select All That Apply

    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.

    Explanation & Rationale

    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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