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A Patient Who Was in a Fight Sustained Several Direct

Question 27

Multiple Choice

A patient who was in a fight sustained several direct blows to the face. The nurse assesses an elevated pulse (P 108) , elevated respiratory rate (RR 24) , and obvious deformity to the right side of the face. What should the nurse identify as the priority of care for this patient?


A) frequently assessing the blood pressure for signs of shock and initiating IV fluids
B) monitoring the elevated respiratory rate and maintaining the airway
C) monitoring the elevated pulse rate and looking for signs of pallor
D) frequently assessing for facial pain and administering pain medication p.r.n.

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