The nurse is concerned that a patient with traumatic chest ...

[cabate]

The nurse is concerned that a patient with traumatic chest injures is developing respiratory distress. What assessment findings led the nurse to come to this conclusion?
 
  Select all that apply.
 
  1. combative behavior
  2. absent breath sounds in left lower lobe
  3. pedal and popliteal pulses weak and irregular
  4. temperature raised 2 degrees over the last 4 hours
  5. oxygen saturation 86 on 40 oxygen face mask

Question 2

Emergency personnel are preparing to complete an on-the-scene rapid assessment of a victim of a motor vehicle crash. In which order should the victim's assessment be completed? Place the assessments in order of importance.
 
  1. assessment for obvious injuries
  2. Champion Revised Trauma Scoring System
  3. airway and breathing assessment
  4. circulation assessment
  5. level of consciousness and pupillary function

[matt95]

Answer to Question 1

Correct Answer: 1, 2, 5

An early sign of an ineffective airway is a change in the patient's behavior. If the patient becomes combative, the nurse immediately assesses the effectiveness of the airway. Absent breath sounds can indicate airway obstruction. Oxygen saturation is a measurement of airway effectiveness. Oxygen flow should be adjusted to keep saturation level between 94 and 100. Changes in lower extremity pulses indicate an alteration in perfusion. Changes in body temperature indicate an infectious process.

Answer to Question 2

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

The airway and breathing assessment is completed first and the circulatory assessment second, following the principle of the ABCs. The airway must be patent to provide oxygen to the vital organs. The level of consciousness and pupillary function will indicate any head injury/spinal cord injury that must be immobilized before transport. The fourth step is to assess for obvious injuries. The Champion Revised Trauma Scoring System will indicate the patient's chance of survival based on the Glasgow Coma Scale, systolic blood pressure, and respiratory rate.

[cabate]

Thank you

[matt95]

Happy to help you