ENPC 6th Ed. Chap 5 Initial Assessment

Question 1

Are viral signs a priority on patient arrival?

Answer 1

NO (75)

Question 2

How can you measure urine output by weighing diapers?

Answer 2

One gram of weight is equivalent to 1ml of urine (79)

Question 3

What amount of urine output would be concerning?

Answer 3

< 1ml/kg/hr can reflect poor end organ perfusion (79)

Question 4

How is alertness evaluated in the Primary Survey A?

Answer 4

Using the AVPU mnemonic (71)

Question 5

Besides Airway and Alertness, what else should be considered during the Primary Survey A?

Answer 5

The need for a C-collar (70)

Question 6

How is an oral airway measured?

Answer 6

From the corner of the mouth to the angle of the jaw (71)

Question 7

How is an NPA measured?

Answer 7

From the nares to the top of the earlobe (71)

Question 8

How may a nurse approximate a ped ETT size?

Answer 8

By using an ETT the size of the little finger (71 BX)

Question 9

Where should the nurse auscultate to confirm bilateral breath sounds?

Answer 9

Mid axillary to reduce the likelihood of referred breath sounds (71)

Question 10

Where should the nurse palpate for a pulse in an infant?

Answer 10

brachial (71)

Question 11

Where should the nurse palpate for a pulse on a child?

Answer 11

Carotid or femoral (71)

Question 12

Describe how the pulses may be in a patient compensating for shock?

Answer 12

“a weak peripheral pulse compared to a central pulse” (71)

Question 13

What circulatory assessment should prompt the nurse to initiate a PALS algorithm intervention?

Answer 13

HR <60 AND signs of poor perfusion (72)

Question 14

What is the volume for a fluid bolus in an neonate?

Answer 14

10ml/kg over 5-10 min. (72)

Question 15

What is the volume for a fluid bolus in a child?

Answer 15

20ml/kg (72)

Question 16

What is the volume of a blood transfusion in a child?

Answer 16

10ml/kg (72)

Question 17

What does a PEWS score of > 2 indicate?

Answer 17

indicates a likely need for intervention (80)

Question 18

Mnemonic for just keep reavaluating?

Answer 18

VIPP (vitals, identify abnormalities, primary survey, pain) (80)

Question 19

How is disability assessed?

Answer 19

Using GCS (72)

Question 20

In what time frame can the Primary Survey be completed?

Answer 20

In 2 minutes if no issues are found (74)

Question 21

At what points of the Survey does PERRLA and Cardinal fields of gaze take place?

Answer 21

PERRLA during “Disability” and Cardinal Fields during “Head to Toe” of face and neck (78)

Question 22

When are heart tones auscultated?

Answer 22

During “Head to Toe” Chest (78)

Question 23

When are breath sounds auscultated?

Answer 23

During Primary Survey “Airway” (71) and during “Head to Toe” chest (78)

Question 24

During the Head to Toe assessment, under Pelvis and Perineum, what should the nurse assess for?

Answer 24

contraindications to inserting a Foley (blood at the meatus, scrotal/perineal edema or ecchymosis) (78)