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    HESI Exit Exam AQuestion 110
    110 / 117
    HESI Exit Exam A
    Select All That Apply

    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.

    Explanation & Rationale

    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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