John, a 35-year-old male involved in a motor vehicle accident, presents with a contusion across his chest from the seatbelt. Which two combined assessments should the nurse prioritize to detect potential complications?
Assess for sternal tenderness and check for skin abrasions.
Assess for sternal tenderness and measure oxygen saturation levels.
Measure blood pressure and observe for signs of localized infection
Measure oxygen saturation levels and auscultate lung sounds
The Correct Answer is D
A. While assessing sternal tenderness is relevant, skin abrasions may not directly indicate complications from the chest contusion.
B. Sternal tenderness can indicate underlying injuries but is not the priority compared to auscultation of the lung zones, and measuring oxygen saturation levels is crucial for assessing respiratory function and detecting potential complications such as respiratory distress or hypoxemia.
C. Blood pressure measurement and observation for signs of localized infection are important assessments but may not be directly related to complications from a chest contusion.
D. This is because a contusion across the chest from the seatbelt can cause rib fractures, pneumothorax, hemothorax, or pulmonary contusion, which can impair gas exchange and oxygenation. Measuring oxygen saturation levels and auscultating lung sounds can help detect these complications and guide appropriate interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A ,B,C,D
No explanation
Correct Answer is B
Explanation
A. A urine output of 300 ml/hr and low specific gravity are not indicative of normal renal function.
B. Diabetes insipidus is characterized by excessive urine output (polyuria) with low urine specific gravity.
C. Acute kidney injury would typically present with oliguria (decreased urine output) or anuria (absence of urine output).
D. Urinary tract infection would typically present with other signs such as dysuria, urgency, and possibly fever, but not necessarily altered urine output and specific gravity.
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