Nursing Skills Flashcards

A trauma patient requires rapid fluid resuscitation through a large-bore IV catheter. Which gauge is most appropriate for this situation?

Answer: 14-gauge or 16-gauge

Large-bore IV catheters (14- or 16-gauge) are recommended for rapid fluid resuscitation in trauma patients because they allow the highest flow rates.

During a trauma assessment, the nurse notes paradoxical chest wall movement. This finding is most consistent with which injury?

Answer: Flail chest

Paradoxical chest wall movement, where a segment moves inward on inspiration and outward on expiration, is the hallmark sign of flail chest.

Which nursing intervention is the priority when caring for a patient with a suspected cervical spine injury?

Answer: Maintaining manual in-line stabilization

Manual in-line stabilization of the cervical spine is the priority to prevent secondary spinal cord injury during assessment and interventions.

A trauma nurse is preparing to assist with a chest tube insertion for a hemothorax. The correct anatomical landmark for insertion is:

Answer: Fifth intercostal space, anterior axillary line

The fifth intercostal space at the anterior axillary line (or midaxillary line) is the standard insertion site for a chest tube to drain a hemothorax.

Which assessment finding in a trauma patient indicates the need for immediate surgical intervention?

Answer: Initial chest tube output of 1,500 mL of blood

An initial chest tube output of 1,500 mL or more indicates a massive hemothorax requiring emergent thoracotomy.

When performing a focused assessment with sonography for trauma (FAST), which area is NOT routinely examined?

Answer: Bilateral lung apices

The standard FAST exam evaluates four areas: right upper quadrant, left upper quadrant, suprapubic region, and subxiphoid (pericardial) view. Bilateral lung apices are not part of the standard FAST.

A trauma patient presents with Beck's triad. Which combination of signs does this include?

Answer: Hypotension, distended neck veins, muffled heart sounds

Beck's triad — hypotension, distended neck veins, and muffled heart sounds — is the classic presentation of cardiac tamponade.

During trauma resuscitation, which blood product should be administered first in a massive transfusion protocol?

Answer: Packed red blood cells (PRBCs)

Packed red blood cells are administered first to restore oxygen-carrying capacity. Current protocols emphasize a balanced ratio of PRBCs, plasma, and platelets.

A trauma nurse is assessing a patient using the Glasgow Coma Scale. The patient opens eyes to pain, makes incomprehensible sounds, and exhibits abnormal flexion. What is the GCS score?

Answer: 7

Eye opening to pain = 2, incomprehensible sounds = 2, abnormal flexion = 3, totaling a GCS of 7.

Which intervention is contraindicated in a patient with a suspected basilar skull fracture?

Answer: Nasogastric tube insertion

Nasogastric tube insertion is contraindicated in suspected basilar skull fracture due to the risk of intracranial penetration through the cribriform plate.

A trauma patient's arterial blood gas shows pH 7.28, PaCO2 28 mmHg, HCO3 14 mEq/L, and lactate 6.2 mmol/L. This pattern is most consistent with:

Answer: Metabolic acidosis with respiratory compensation

The low pH, low bicarbonate, and elevated lactate indicate metabolic acidosis. The low PaCO2 reflects respiratory compensation (hyperventilation).

When applying the TNCC primary survey framework, which component is assessed during 'B' (Breathing)?

Answer: Breath sounds and chest wall integrity

The 'B' in the primary survey stands for Breathing and Ventilation, which includes assessment of breath sounds, chest wall movement, respiratory rate, and chest integrity.