QUESTIONSARE HERE ,ALL ANSWERED CORRECTLY
LATEST UPDATED JUNE 2023)TEST BANK WITH DEFARENT
VERSIONS
What is the Mnemonic for the Initial Assessment? - A = Airway with simultaneous
cervical spine protection
B = Breathing
C = Circulation
D = Disability (neurologic status)
E = Expose/Environmental controls (remove clothing and keep the patient warm)
What is the Mnemonic for the Secondary Assessment? - F = Full set of VS/Focused
adjuncts (includes cardiac monitor, urinary catheter, and gastric tube)/Family presence
G = Give comfort measures (verbal reassurance, touch, and pharmacologic and
nonpharmacologic management of pain).
H = Hx and Head-to-toe assessment
I = Inspect posterior surfaces
Where do you listen to auscultate breath sounds? - Auscultate the lungs bilaterally at
the second intercostal space midclavicular line and at the fifth intercostal space at the
anterior axillary line.
What are the late signs of breathing compromise? - - Tracheal deviation
- JVD
What are signs of ineffective breathing? - - AMS
,- Cyanosis, especially around the mouth
,- Asymmetric expansion of chest wall
- Paradoxical movement of the chest wall during inspiration and expiration
- Use of accessory muscles or abdominal muscles or both or diaphragmatic breathing
- Sucking chest wounds
- Absent or diminished breath sounds
- Administer O2 via NRB or assist ventilations with a bag-mask device, as indicated
- Anticipate definitive airway management to support ventilation.
Upon initial assessment, what type of oxygen should be used for a pt breathing
effectively? - A tight-fitting nonrebreather mask at 12-15 lpm.
What intervention should be done if a pt presents with effective circulation? - - Insert 2
large caliber IV's
- Administer warmed isotonic crystalloid solution at an appropriate rate
What are signs of ineffective circulation? - - Tachycardia
- AMS
- Uncontrolled external bleeding
- Pale, cool, moist skin
- Distended or abnormally flattened external jugular veins
- Distant heart sounds
What are the interventions for Effective/Ineffective Circulation? - - Control any
uncontrolled external bleeding by:
- Applying direct pressure over bleeding site
- Elevating bleeding extremity
- Applying pressure over arterial pressure points
- Using tourniquet (last resort).
- Cannulate 2 large-caliber IV's and initiate infusions of an isotonic crystalloid solution
- Use warmed solution
- Use pressure bags to increase speed of IVF infusion
- Use blood administration tubing for possible administration of blood
- Use rapid infusion device based on protocol
- Use NS 0.9% in same tubing as blood product
- IV = surgical cut-down, central line, or both.
- Blood sample to determine ABO and Rh group
- IO in sternum, legs, arms or pelvis
- Administer blood products
- PASG (without interfering with fluid resuscitation)
How do you assess Mnemonic "D"? - DISABILITY
A = Alert
V = Verbal
P = Pain
U = Unresponsive
, - GCS