Nursing Primary Assessment Process
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Questions and Answers

What is the first step that nurses should undertake in every encounter with patients?

  • Administer medication
  • Perform a focused assessment
  • Take vital signs
  • Complete a primary assessment (correct)

    • What should nurses do if a patient is not responding and they hear stridor during the assessment?

  • Insert nasopharyngeal airways
  • Administer oxygen
  • Send for immediate help (correct)
  • Check for a pulse

    • What should be used to clear the airway if there is nothing visible when trying to manage a compromised airway?

  • Geudels
  • Yankeer sucker (correct)
  • Oxygen mask
  • Nasopharyngeal airway

    • When should airway adjuncts like geudels or nasopharyngeal airways be inserted according to the text?

    <p>If the patient is unconscious</p> Signup and view all the answers

    What is the first indication of a patient exhibiting moderate to severe respiratory distress?

    <p>Speaking in broken sentences</p> Signup and view all the answers

    Which of the following is NOT a sign of respiratory distress?

    <p>Speaking in full sentences</p> Signup and view all the answers

    What muscle groups can be involved when a patient is using accessory muscles for breathing?

    <p>Intercostal muscles and abdominal wall muscles</p> Signup and view all the answers

    What does cyanosis indicate in terms of a patient's respiratory function?

    <p>Severe respiratory distress</p> Signup and view all the answers

    Which of the following is a sign of haemodynamic compromise in a patient?

    <p>Complaining of dizziness</p> Signup and view all the answers

    If a patient has no radial pulse, what does this suggest about their blood pressure?

    <p>&lt;80 mmHg systolic BP</p> Signup and view all the answers

    What is one of the first signs to look for to assess if a patient is in respiratory distress?

    <p>Speaking in broken sentences</p> Signup and view all the answers

    Which of the following is a clear indicator of moderate to severe respiratory distress in a patient?

    <p>Use of accessory muscles for breathing</p> Signup and view all the answers

    What does a patient speaking in single words suggest about their respiratory function based on the text?

    <p>They are exhibiting signs of respiratory distress</p> Signup and view all the answers

    Which of the following is a sign that a patient might be 'tiring' in terms of their respiratory function?

    <p>Decrease in respiratory rate without improvement in vital signs</p> Signup and view all the answers

    Why is it crucial to observe for paradoxical breathing in a patient showing signs of respiratory distress?

    <p>It can help identify specific muscle groups involved in breathing</p> Signup and view all the answers

    In assessing breathing, what does the presence of cyanosis typically indicate?

    <p>Signs of severe respiratory distress</p> Signup and view all the answers

    If a patient is using shoulder shrugging as an accessory muscle while breathing, what does this suggest?

    <p>'Tiring' in their respiratory function</p> Signup and view all the answers

    Why is it important to monitor the work of breathing in a patient exhibiting respiratory distress?

    <p>To evaluate the effectiveness of interventions and prevent respiratory fatigue</p> Signup and view all the answers

    What is the purpose of a primary assessment for nurses?

    <p>To identify and correct threats to patient safety</p> Signup and view all the answers

    Which abnormal sound should nurses be concerned about when assessing a patient's airway?

    <p>Snoring (occlusion of the pharynx by the tongue or palate)</p> Signup and view all the answers

    What action should be taken if a patient is unconscious and has a compromised airway?

    <p>Immediately send for help by pressing the emergency buzzer</p> Signup and view all the answers

    Which position can be used to maximize airway capacity in patients on spinal precautions?

    <p>Head tilt 'sniff position'</p> Signup and view all the answers

    What should nurses do if they hear gurgling sounds during the assessment of a patient's airway?

    <p>Attempt to clear the airway by using appropriate techniques</p> Signup and view all the answers

    When should nurses insert airway adjuncts like nasopharyngeal airways according to the text?

    <p>If the patient is unconscious</p> Signup and view all the answers

    Which action should nurses take if a patient is not responding during the airway assessment?

    <p>Listen for abnormal sounds indicating potential issues</p> Signup and view all the answers

    What do stridor, snoring, wheezing, and gurgling sounds indicate in a patient's airway?

    <p>Possible blockages or obstructions at different levels</p> Signup and view all the answers

    What should nurses do if they hear hoarseness in a patient's voice during an airway assessment?

    <p>Investigate further as it could be related to airway issues</p> Signup and view all the answers

    What technique can be used by nurses to clear a compromised airway when no obstructions are visible?

    <p>Head tilt 'sniff position'</p> Signup and view all the answers

    What immediate action should be taken if a patient exhibits stridor during an airway assessment?

    <p>Send for help by pressing the emergency buzzer</p> Signup and view all the answers

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