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Home Q & A Board Biology-Related Homework Help Medicine Nursing and Clinical
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colleen colleen
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11 years ago
The nurse is caring for a patient who was admitted following a fight. The patient had several direct blows to the face. The assessment reveals normal blood pressure (BP), elevated pulse (P-108), elevated respiratory rate (RR-24), and obvious deformity to the right side of the face. The most important priority for patient care is which of the following?
1. Frequently assess the blood pressure for signs of shock and initiate IV fluids.
2. Monitor the elevated respiratory rate and maintain the airway.
3. Monitor the elevated pulse rate and look for signs of pallor.
4. Frequently assess for facial pain and administer pain medication p.r.n.
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Sunshine ☀ ☼

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#1
Valued Member
11 years ago
2 -- Consider the potential risk for airway compromise with facial fractures. Help the patient clear secretions from the oropharynx and report elevated respiratory rate ( tachypnea) to the physician. Although IV fluids may be initiated, the patient’s assessment does not reflect a significant risk for shock. The injuries will cause the patient to exhibit bruising and discoloration, not pallor. While the patient will require an ongoing pain assessment and management, this is not the most important nursing action.
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colleen Author
wrote...
#2
Valued Member
11 years ago
Thank you so much Smiling Face with Open Mouth
Sunshine ☀ ☼
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