A patient has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?

Apply oxygen at 100%.

Assess the heart rate.

Ensure a patent airway.

Start two large-bore IV lines.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Applying oxygen at 100% is an important step in managing a patient with a life-threatening chest injury. However, ensuring a patent airway is the first priority, as it is crucial to maintain airway patency to facilitate oxygen delivery. Without an open airway, oxygen administration would be ineffective.

Choice B reason:

Assessing the heart rate is part of the initial assessment in emergency care. However, the priority is to ensure a patent airway, as a compromised airway can lead to hypoxia and rapid deterioration of the patient's condition. Heart rate assessment can follow once airway patency is confirmed.

Choice C reason:

Ensuring a patent airway is the top priority in the emergency management of a patient with a life-threatening chest injury. Airway patency is essential for effective ventilation and oxygenation. If the airway is obstructed, the patient cannot receive oxygen or expel carbon dioxide, leading to life-threatening complications.

Choice D reason:

Starting two large-bore IV lines is important for fluid resuscitation and medication administration. However, the primary focus should be on ensuring a patent airway, as immediate airway management is critical to the patient's survival in the acute phase of a life-threatening chest injury.

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Correct Answer is A

Explanation

Choice A reason:

Administering Nitroglycerin 0.4 mg sublingually STAT for the client experiencing chest pain should be the nurse's priority because chest pain can be indicative of a myocardial infarction (heart attack), which is a medical emergency. Quick administration of Nitroglycerin can help to relieve chest pain, improve blood flow to the heart, and prevent further cardiac damage.

Choice B reason:

While administering Lorazepam 2 mg IV for the client experiencing restlessness and picking at tubing is important for patient safety and comfort, it is not as urgent as addressing potential cardiac issues indicated by chest pain.

Choice C reason:

Administering Morphine sulfate 4 mg IV for incisional pain management is necessary for the patient’s comfort and pain control but is not as critical as treating potential life-threatening chest pain.

Choice D reason:

Administering one unit of packed red blood cells STAT for the client with a hemoglobin of 9.5 g/dL is important but does not take precedence over the immediate risk of a myocardial infarction. The hemoglobin level, while low, is not immediately life-threatening compared to the chest pain scenario.

A. Need for increased FiO2 administration. B. Increased inflation of the lungs. C. Prevention of alveolar collapse during expiration. D. Prevention of barotrauma to the lung tissue.

Correct Answer is C

Explanation

Choice A reason:

The application of PEEP does not inherently increase the need for FiO2 (fraction of inspired oxygen) administration. PEEP helps improve oxygenation, potentially reducing the need for higher FiO2 levels.

Choice B reason:

While PEEP can contribute to better lung inflation by keeping the alveoli open, this is a secondary effect. The primary goal of PEEP is to prevent alveolar collapse at the end of expiration.

Choice C reason:

PEEP prevents alveolar collapse during expiration, which is its primary therapeutic effect. By maintaining a certain level of pressure in the lungs at the end of expiration, PEEP ensures that the alveoli remain open, improving gas exchange and oxygenation.

Choice D reason:

Although PEEP can help reduce the risk of atelectasis (collapse of part or all of a lung), it does not directly prevent barotrauma. Barotrauma is related to high airway pressures, and careful monitoring of ventilator settings is necessary to avoid it.

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A patient has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?

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