Author Question: During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's ... (Read 75 times)

dbose · **on:** Jun 25, 2018

During the primary survey of a patient with severe leg trauma, the nurse observes that the patient's left pedal pulse is absent and the leg is swollen. Which action will the nurse take next?

a. Send blood to the lab for a complete blood count.
b. Assess further for a cause of the decreased circulation.
c. Finish the airway, breathing, circulation, disability survey.
d. Start normal saline fluid infusion with a large-bore IV line.

Question 2

The nurse reviews the electronic medical record for a patient scheduled for a total hip replacement. Which assessment data shown in the accompanying figure increase the patient's risk for respiratory complications after surgery?

a. Albumin level and recent weight loss
b. Mild confusion and recent weight loss
c. Age and recent arthroscopic procedure.
d. Anemia and recent arthroscopic procedure

nikmaaacs · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: D
The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a complete blood count is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated.

Answer to Question 2

ANS: A
The patient's recent weight loss and low protein stores indicate possible muscle weakness, which make it more difficult for an older patient to recover from the effects of general anesthesia and immobility associated with the hip surgery. The other information will also be noted by the nurse but does not place the patient at higher risk for respiratory failure.