Author Question: A patient with thoracic injuries sustained in a multivehicle crash is demonstrating an alteration in ... (Read 59 times)

big1devin · **on:** Jun 25, 2018

A patient with thoracic injuries sustained in a multivehicle crash is demonstrating an alteration in perfusion. What should the nurse do to help this patient?

Select all that apply.

1. Auscultate lung sounds.
2. Measure blood pressure.
3. Measure central venous pressure.
4. Reduce rate of intravenous fluids.
5. Assess for jugular vein distention.

Question 2

A patient receiving a unit of packed red blood cells for hypovolemic shock is demonstrating signs of a transfusion reaction. In which order should the nurse provide care to this patient?

1: Stop the transfusion and notify the physician
2: Compare the blood slip with the unit of blood
3: Assess vital signs and associated manifestations
4: Save the blood bag and tubing for laboratory analysis
5: Collect urine and venous blood samples according to policy

mochi09 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 1, 2, 3, 5

For an alteration in perfusion, the nurse should auscultate lung sounds, measure blood pressure, measure central venous pressure, and assess for jugular vein distention. Reducing intravenous fluids could exacerbate the problem.

Answer to Question 2

Correct Answer: 1, 3, 2, 4, 5

If manifestations of a blood transfusion reaction occur, the first step is to immediately stop the infusion and notify the physician. The second step is to assess vital signs and assess for other manifestations. The third step is to compare the blood slip with the unit of blood to ensure that an identification error was not made. The fourth step is to save the blood bag and any remaining blood for return to the laboratory for testing to determine the cause of the reaction. The fifth step is to follow organizational policy for collecting urine and venous blood samples.