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 D
Explanation
A. While antiepileptic drugs are sometimes used to manage neuropathic pain, the priority in George's case is preventing complications related to diabetic neuropathy.
B. Dialysis is not indicated for neuropathy management.
C. While managing blood glucose levels is important in diabetes management, immediate insulin administration may not be necessary unless George is experiencing hyperglycemic crisis.
D. This is the priority intervention to prevent complications such as diabetic foot ulcers and infections.
Correct Answer is D
Explanation
A. While cardiac rehabilitation may be necessary for Timothy in the future due to his cardiomyopathy, his current symptoms and elevated creatine kinase levels warrant immediate attention to other potential complications.
B. While scoliosis screening may be necessary given Timothy's symptoms, it is not the most urgent priority.
C. Pain management may be necessary for Timothy, but his respiratory status should be assessed first to ensure adequate oxygenation.
D. Given Timothy's symptoms and potential complications such as respiratory muscle weakness associated with his elevated creatine kinase levels, a respiratory assessment is the most urgent priority to ensure proper oxygenation and ventilation
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