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.