A young adult is brought to the Emergency Department (ED) after a motor vehicle accident (MVA). The patient has severe right chest pain where there was impact with the steering wheel. Which is the priority patient goal?
Reduce the patient's anxiety
Assure adequate circulating volume
Decrease the patient's chest pain
Maintain adequate oxygenation
The Correct Answer is D
A) Reduce the patient's anxiety:
While reducing anxiety is an important aspect of patient care, particularly in emergency situations, it is not the priority when life-threatening conditions may be present. Anxiety reduction can be addressed after ensuring that the patient’s more critical physiological needs (such as adequate oxygenation and circulation) are met.
B) Assure adequate circulating volume:
Maintaining adequate circulating volume is important, especially in trauma cases where blood loss is a concern. However, adequate oxygenation takes precedence over circulating volume in this scenario because without proper oxygenation, the patient’s vital organs and tissues may suffer from hypoxia, leading to further complications.
C) Decrease the patient's chest pain:
Chest pain following a motor vehicle accident (MVA) can be a symptom of serious injuries, such as rib fractures, pneumothorax, or even a cardiac contusion. While relieving pain is important for comfort and overall well-being, the priority in the immediate post-trauma phase is to ensure that the patient is receiving adequate oxygen.
D) Maintain adequate oxygenation:
The most critical concern after trauma, especially in a case involving chest impact, is ensuring that the patient is adequately oxygenated. Chest trauma can cause injuries to the lungs or pleural space (e.g., pneumothorax, hemothorax), leading to compromised oxygen exchange. The priority is to assess and maintain the patient's airway, breathing, and oxygenation first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Maintaining strict bedrest for first 24 hours:
While bedrest is often recommended in the early stages following a myocardial infarction (MI), the priority nursing intervention is to reduce oxygen demand on the heart, which can be achieved through pain management and controlling the workload on the heart, rather than solely relying on bedrest. Bedrest alone may not address the underlying physiological needs of the heart, such as reducing ischemia or controlling pain.
B) Measuring urine output hourly and performing daily weights:
Monitoring urine output and performing daily weights are important in managing fluid balance, especially for those with heart failure or volume overload. However, in the acute phase of an anterior wall myocardial infarction, the priority intervention is addressing the oxygen demand on the heart and providing pain relief, which is more immediate in stabilizing the client and reducing myocardial injury.
C) Keeping the environment quiet to decrease cardiac workload:
While creating a calm and quiet environment helps in reducing stress and decreasing cardiac workload, it is still secondary to actively managing the oxygen demand of the heart. Decreasing the workload of the heart is essential, but this is done more effectively through interventions such as pain management, oxygen therapy, and medications that reduce myocardial oxygen demand (e.g., nitroglycerin, beta-blockers).
D) Reducing oxygen demand and providing pain control:
This is the highest priority intervention for a client who has suffered an acute anterior wall myocardial infarction (MI). Pain from an MI increases the heart's oxygen demand and can exacerbate ischemia. Pain relief, often with morphine, not only reduces pain but also helps in vasodilation, reducing the heart's workload. Additionally, oxygen therapy should be given to ensure adequate oxygenation, and medications like beta-blockers, nitroglycerin, and ACE inhibitors are used to reduce the workload of the heart.
Correct Answer is ["90"]
Explanation
Given:
Ordered dose of Alteplase: 0.9 mg/kg
Client weight: 220 pounds
Step 1: Convert the client's weight from pounds to kilograms:
1 pound (lb) = 0.453592 kilograms (kg)
Client weight in kg = 220 lbs x 0.453592 kg/lb = 99.76824 kg
Step 2: Calculate the total dose of Alteplase:
Total dose (mg) = Ordered dose (mg/kg) xClient weight (kg)
Total dose (mg) = 0.9 mg/kg x 99.76824 kg
Total dose (mg) = 89.801416 mg
Step 3: Round to the nearest whole number:
Total dose (mg) ≈ 90 mg
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