A patient was brought to the ED after falling from a tree. The patient has an open femur fracture and is bleeding from several lacerations across the abdomen and chest

Question

The patient cannot remember what happened, the skin is cool and pale, and the femoral pulses are weak. Which nursing interventions are necessary? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Notify the health care provider immediately.
2. Start two large-bore IV lines if not already in place.
3. Apply pressure to bleeding wounds.
4. Apply a splint to the injured leg.
5. Place the patient on oxygen.

Answer 1

1,2,3,5
Rationale 1: This situation is emergent and immediate treatment, possibly surgical treatment, is necessary.
Rationale 2: The nurse should establish venous access if not already in place and should protect any venous access already established.
Rationale 3: External pressure is the best method of reducing bleeding from wounds.
Rationale 4: Application of a splint can wait until more important actions have been taken.
Rationale 5: The patient is in danger of hypovolemic shock from blood loss. The nurse should increase oxygen in the remaining blood.