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.
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Related Questions
Correct Answer is D
Explanation
A. Prepare for immediate abdominal surgery
There is no indication of active hemorrhage or peritonitis at this point. Further assessment is needed before deciding on surgery.
B. Determine if there are any allergies to food or drugs
Allergy history is important, but it is not the immediate priority for this client.
C. Administer antibiotics as ordered after culture results are available
Antibiotics may be needed if infection is suspected, but the priority is assessing kidney function due to the risk of rhabdomyolysis from muscle breakdown.
D. Obtain a urine specimen
Flank pain after a crush injury suggests possible rhabdomyolysis or kidney damage. The urine should be tested for myoglobinuria (tea-colored urine), hematuria, or kidney injury markers.
Correct Answer is C
Explanation
A. Initial stage of septic shock
Septic shock typically presents with warm, flushed skin in the early phase due to vasodilation. This client has cold and clammy skin, which is more consistent with hypovolemic shock.
B. Refractory stage of obstructive shock
Obstructive shock (e.g., from cardiac tamponade or pulmonary embolism) would present with jugular vein distention, muffled heart sounds, or severe respiratory distress, which are not seen in this case.
C. Progressive stage of hypovolemic shock
The client has classic signs of hypovolemic shock due to fluid loss (nausea, vomiting, diarrhea). The progressive stage is indicated by hypotension, tachycardia, and end-organ dysfunction (altered mental status, cool/clammy skin).
D. Compensatory stage of diabetic shock
"Diabetic shock" is not a standard classification of shock. The compensatory stage would still have an adequate blood pressure due to SNS activation, but this patient already has profound hypotension.
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