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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A) Ventilator-associated pneumonia (VAP):
Ventilator-associated pneumonia (VAP) is a type of pneumonia that develops in patients who have been on mechanical ventilation for more than 48 hours. It is a common and serious complication in critically ill patients on ventilators. Symptoms such as fever, green sputum, and right lower lobe crackles are indicative of a respiratory infection, which, in this case, is most likely VAP. VAP typically presents with signs of infection such as elevated temperature, purulent sputum, and new infiltrates on a chest x-ray, in addition to lung crackles.

B) Pulmonary embolism (PE):
Although pulmonary embolism (PE) can cause symptoms like tachypnea, chest pain, and dyspnea, it does not typically cause a fever, green sputum, or localized crackles in the lungs. PE is usually characterized by sudden onset of respiratory distress, often accompanied by hemoptysis or chest pain, and would not typically present with the localized findings in the lower lobe (e.g., crackles).

C) Stress ulcer:
Stress ulcers can occur in critically ill patients, especially those on mechanical ventilation, due to the stress response and reduced blood flow to the stomach. However, stress ulcers typically cause gastrointestinal symptoms, such as melena (black, tarry stools) or hematemesis (vomiting blood).

D) Pneumothorax:
A pneumothorax occurs when air accumulates in the pleural space, causing a collapse of the lung. It can lead to symptoms such as sudden chest pain, dyspnea, and diminished breath sounds on one side of the chest. However, it would not typically cause fever, green sputum, or localized crackles.

A. Intestines B. Liver C. Spleen D. Stomach

Correct Answer is C

Explanation

A) Intestines:
While abdominal trauma can affect the intestines, Kehr's sign, Cullen's sign, and Gray Turner's sign are more commonly associated with damage to the spleen rather than the intestines. Kehr's sign, in particular, is a hallmark of splenic injury, with pain referred to the left shoulder due to diaphragmatic irritation from blood in the peritoneum.

B) Liver:
Liver injuries often present with right upper quadrant pain, jaundice, and elevated liver enzymes. While liver injuries can cause internal bleeding, Cullen's and Gray Turner's signs are more closely associated with retroperitoneal bleeding from the spleen rather than liver injuries. Kehr's sign, which is left-sided shoulder pain, would not typically indicate a liver injury.

C) Spleen:
The spleen is the most likely abdominal organ affected in this case due to the left-sided rib fractures. When the spleen is injured (often as a result of blunt trauma), it can cause intraperitoneal hemorrhage. This bleeding can irritate the diaphragm, leading to Kehr's sign, which presents as left shoulder pain. Additionally, Cullen's sign (periumbilical bruising) and Gray Turner's sign (flank bruising) are indicative of retroperitoneal bleeding, which can occur with splenic rupture or laceration.

D) Stomach:
While stomach injuries can occur with blunt abdominal trauma, they are less likely to cause the signs and symptoms seen in this patient (Kehr's, Cullen's, and Gray Turner's signs). Stomach trauma typically leads to pain and potential perforation, but it doesn't often cause the peritoneal bleeding patterns seen with splenic injuries.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has been on a mechanical ventilator for three days develops a fever of 101 degrees Fahrenheit green sputum, and right lower lobe crackles. The nurse contacts the physician regarding possible development of which complication?

Correct Answer is A

Explanation

In providing care to a patient who sustained left sided 10th through 12th rib fractures, the nurse notes Kehr's Cullen's and Gray Turner's signs during assessment. Which abdominal organ is most likely to be affected by this trauma?

Correct Answer is C

Explanation

The neurologic assessment of a patient indicated impaired function of the glossopharyngeal nerve (CN 10) and the vagus nerve (C.N X). Based on these findings, the nurse plans to;

A patient is ordered 1 mg/kg of furosemide IV push. The patient weights 121 lbs. The medication is supplied 40 mg/10 mL. How many mL should the nurse administer? (round to the nearest tenth)

The nurse is caring for client who is diagnosed with hypertrophic cardiomyopathy. Which medical Intervention should the nurse anticipate for this client for the complications of dysrhythmias?

The nurse assesses the patient with a spinal cord injury at the level C-7 and finds warm, flushed skin with profuse sweating above the level of injury, and pale, cold skin below the level of injury. The patient is bradycardic, but severely hypertensive. What are the priority nursing interventions?

The nurse is caring for a patient with an acute head injury. Which assessment finding would first alert the nurse that the patient is developing an increase in intracranial pressure (ICP)?

The nurse is caring for a client with infectious endocarditis. Which information obtained from the health history could have contributed to the development of the disease progress?

A patient is to receive a continuous infusion of Diltiazem at 2.5 mg hr for Atrial fibrillation, The medication is supplied 125 mg of Diltlazem in 125 mL of IV fluid. At what rate should the nurse set the IV pump? (round to the nearest tenth)