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NUR 445 EXAM 4 Questions and Answers with
Complete Solutions UPDATED!!!
what is primary survey
Primary is Identifying life-threatening conditions and institute
management
o Identify life threatening conditions and institute management
ABCDE
§ Airway
§ Breathing
§ Circulation
§ Disability -> LOC & GCS
§Exposure/Environment -Strip them
what is secondary survey
Secondary is at the hospital (FGHI)
o Focused assessment with sonography for Trauma (FAST):
§ Ultrasound that looks for free fluid(blood) in the abdominal
cavity, pericardium, or pelvis
§ Insertion of foley to monitor I&Os
§ Insertion of gastric tube to empty stomach and prevent
aspiration
§ Initial surgical stabilization
o Full Set of Vitals/focused adjuncts/family presence
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o Give comfort measures
o History and Head-to-Toe
o Inspect posterior surfaces
o Remove-cut off all clothing
§ May be evidence so DO NOT TRASH CLOTHES
Chest Trauma is most often caused by
by motor vehicle collisions
treatment for chest trauma
ABC'S
Morphine allows the patient to breathe effectively
EARLY S/S OF HYPOXEMIA
Dyspnea, agitation and anxiety, then decreased LOC
Priority interventions for suspected C-Spine or head injury
C-COLLAR
How would you assess the airway of a patient with suspected
head/neck injury
· Modified jaw thrust
· DO NOT REMOVE THE C-Collar
Nursing interventions do patients with blunt chest trauma
(ABCD)
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· Assess the Airway maintaining C-Spine stabilization
· Assess breathing -> breath sounds, even chest rise (uneven
chest rise, absent chest sounds)
o Chest tube for hemo/pneumo
o Chest pain
§ Splint, deep breath and cough, Incentive spirometer
· Circulation
o IV fluid resuscitation to maintain hemodynamic stability
o Hemothorax -> May need blood transfusion
· Disability -> level of consciousness (GCS scale)
Signs and symptoms of tension pneumothorax
· Tracheal deviation toward the unaffected side and
asymmetrical chest movement is a hallmark sign
· Positive pressure in the pleural cavity and affected lung
collapses
· Pain
· SOB
· Trouble breathing
· assess subcutaneous emphysema ->crackling feeling under the
skin
TREATMENT FOR BLUNT CHEST TRAUMA
NUR 445 EXAM 4 Questions and Answers with
Complete Solutions UPDATED!!!
what is primary survey
Primary is Identifying life-threatening conditions and institute
management
o Identify life threatening conditions and institute management
ABCDE
§ Airway
§ Breathing
§ Circulation
§ Disability -> LOC & GCS
§Exposure/Environment -Strip them
what is secondary survey
Secondary is at the hospital (FGHI)
o Focused assessment with sonography for Trauma (FAST):
§ Ultrasound that looks for free fluid(blood) in the abdominal
cavity, pericardium, or pelvis
§ Insertion of foley to monitor I&Os
§ Insertion of gastric tube to empty stomach and prevent
aspiration
§ Initial surgical stabilization
o Full Set of Vitals/focused adjuncts/family presence
,2|Page
o Give comfort measures
o History and Head-to-Toe
o Inspect posterior surfaces
o Remove-cut off all clothing
§ May be evidence so DO NOT TRASH CLOTHES
Chest Trauma is most often caused by
by motor vehicle collisions
treatment for chest trauma
ABC'S
Morphine allows the patient to breathe effectively
EARLY S/S OF HYPOXEMIA
Dyspnea, agitation and anxiety, then decreased LOC
Priority interventions for suspected C-Spine or head injury
C-COLLAR
How would you assess the airway of a patient with suspected
head/neck injury
· Modified jaw thrust
· DO NOT REMOVE THE C-Collar
Nursing interventions do patients with blunt chest trauma
(ABCD)
, 3|Page
· Assess the Airway maintaining C-Spine stabilization
· Assess breathing -> breath sounds, even chest rise (uneven
chest rise, absent chest sounds)
o Chest tube for hemo/pneumo
o Chest pain
§ Splint, deep breath and cough, Incentive spirometer
· Circulation
o IV fluid resuscitation to maintain hemodynamic stability
o Hemothorax -> May need blood transfusion
· Disability -> level of consciousness (GCS scale)
Signs and symptoms of tension pneumothorax
· Tracheal deviation toward the unaffected side and
asymmetrical chest movement is a hallmark sign
· Positive pressure in the pleural cavity and affected lung
collapses
· Pain
· SOB
· Trouble breathing
· assess subcutaneous emphysema ->crackling feeling under the
skin
TREATMENT FOR BLUNT CHEST TRAUMA
