The nurse is caring for a client who has suffered a gunshot wound to the anterior chest. The client has been intubated and is currently being ventilated with a bag-valve device. What is the priority intervention for this client now?
Assessment of neurologic status
Obtain IV access with two large bore lines and blood for lab studies
Placement of a naso-gastric tube to decompress the stomach
Placement of an indwelling catheter (Foley) to measure urine output
The Correct Answer is B
A. Assessment of neurologic status
While neurological assessment is important, it is not the priority in this situation. The immediate priority is managing the chest wound and airway to ensure oxygenation and prevent further complications.
B. Obtain IV access with two large bore lines and blood for lab studies
IV access is important for fluid resuscitation and medication administration but is not the immediate priority compared to securing the airway and ensuring ventilation.
C. Placement of a naso-gastric tube to decompress the stomach
Although the naso-gastric tube may be necessary to decompress the stomach later, it is not the priority in the initial management of a client with a gunshot wound to the chest.
D. Placement of an indwelling catheter (Foley) to measure urine output
While measuring urine output is important for monitoring renal function and fluid balance, it is not the priority in this emergency situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. 63% TBSA
This value is too high based on the Rule of Nines calculation.
B. 45% TBSA
This overestimates the burn area.
C. 36% TBSA
Using the Rule of Nines, the TBSA is calculated as follows:
- Entire right arm (anterior + posterior): 9%
- Posterior trunk: 18%
- Posterior right leg: 9%
- Total TBSA = 9% + 18% + 9% = 36%
D. 27% TBSA
This underestimates the affected areas.
Correct Answer is ["C","E","F"]
Explanation
A. The correct rate is 6 mL/hr
The correct calculation should be verified.
B. After contacting the prescriber, Nurse A should anticipate an order for IV Vitamin K
Protamine sulfate, not vitamin K, is the antidote for heparin.
C. The nurses will complete an event report due to the medication error
A medication error must be reported.
D. Nurse A will document about the event report in the patient’s EMR
Incident reports are internal documents and should not be documented in the EMR.
E. The patient has received a dose of heparin over the prescribed amount
Due to the increased concentration, the patient received more heparin than intended.
F. The patient has received 3200 units of heparin from 1700-1900.
This calculation confirms overdosing.
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