29 Questions
What is the first step that nurses should undertake in every encounter with patients?
Complete a primary assessment
What should nurses do if a patient is not responding and they hear stridor during the assessment?
Send for immediate help
What should be used to clear the airway if there is nothing visible when trying to manage a compromised airway?
Yankeer sucker
When should airway adjuncts like geudels or nasopharyngeal airways be inserted according to the text?
If the patient is unconscious
What is the first indication of a patient exhibiting moderate to severe respiratory distress?
Speaking in broken sentences
Which of the following is NOT a sign of respiratory distress?
Speaking in full sentences
What muscle groups can be involved when a patient is using accessory muscles for breathing?
Intercostal muscles and abdominal wall muscles
What does cyanosis indicate in terms of a patient's respiratory function?
Severe respiratory distress
Which of the following is a sign of haemodynamic compromise in a patient?
Complaining of dizziness
If a patient has no radial pulse, what does this suggest about their blood pressure?
<80 mmHg systolic BP
What is one of the first signs to look for to assess if a patient is in respiratory distress?
Speaking in broken sentences
Which of the following is a clear indicator of moderate to severe respiratory distress in a patient?
Use of accessory muscles for breathing
What does a patient speaking in single words suggest about their respiratory function based on the text?
They are exhibiting signs of respiratory distress
Which of the following is a sign that a patient might be 'tiring' in terms of their respiratory function?
Decrease in respiratory rate without improvement in vital signs
Why is it crucial to observe for paradoxical breathing in a patient showing signs of respiratory distress?
It can help identify specific muscle groups involved in breathing
In assessing breathing, what does the presence of cyanosis typically indicate?
Signs of severe respiratory distress
If a patient is using shoulder shrugging as an accessory muscle while breathing, what does this suggest?
'Tiring' in their respiratory function
Why is it important to monitor the work of breathing in a patient exhibiting respiratory distress?
To evaluate the effectiveness of interventions and prevent respiratory fatigue
What is the purpose of a primary assessment for nurses?
To identify and correct threats to patient safety
Which abnormal sound should nurses be concerned about when assessing a patient's airway?
Snoring (occlusion of the pharynx by the tongue or palate)
What action should be taken if a patient is unconscious and has a compromised airway?
Immediately send for help by pressing the emergency buzzer
Which position can be used to maximize airway capacity in patients on spinal precautions?
Head tilt 'sniff position'
What should nurses do if they hear gurgling sounds during the assessment of a patient's airway?
Attempt to clear the airway by using appropriate techniques
When should nurses insert airway adjuncts like nasopharyngeal airways according to the text?
If the patient is unconscious
Which action should nurses take if a patient is not responding during the airway assessment?
Listen for abnormal sounds indicating potential issues
What do stridor, snoring, wheezing, and gurgling sounds indicate in a patient's airway?
Possible blockages or obstructions at different levels
What should nurses do if they hear hoarseness in a patient's voice during an airway assessment?
Investigate further as it could be related to airway issues
What technique can be used by nurses to clear a compromised airway when no obstructions are visible?
Head tilt 'sniff position'
What immediate action should be taken if a patient exhibits stridor during an airway assessment?
Send for help by pressing the emergency buzzer
Learn about the crucial first step of assessing airway, breathing, circulation, disability, and environment in the nursing practice. Explore the structured approach of a primary assessment to ensure patient safety.
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