A patient admitted to the emergency department after a traumatic injury is becoming more and more lethargic and hard to arouse. Periods of apnea are increasing
To protect the patient's airway, the nurse should prepare to assist with which intervention? 1. Monitoring oxygen saturation
2. Endotracheal intubation
3. Assessment of breath sounds
4. Asking the patient if it is becoming difficult to breathe
2
Rationale 1: Simply monitoring oxygen saturation is not sufficient protection for this patient.
Rationale 2: Endotracheal intubation is necessary for a trauma patient who is becoming lethargic and hard to arouse.
Rationale 3: Breath sound assessment is important but will not help protect the airway.
Rationale 4: The patient's perception of breathing difficulty is not important in this situation.
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