A patient with facial and chest injuries from a motor vehicle accident has rhonchi in the upper airways. For which problem should the nurse plan care?
1. inability to clear the airway
2. problem with swallowing
3. changes in oral mucous membrane integrity
4. potential for additional injury
Correct Answer: 1
The patient has facial fractures with subsequent edema that will compromise the airway. The airway must be maintained by helping the patient clear secretions from the oropharynx. There is no evidence of changes in oral mucous membrane integrity or a risk for additional injuries. Although problems swallowing may be a possibility, they are not a priority at this time.
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