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 ["A","C","D"]
Explanation
A. Bend the client’s head toward their chest is correct because Brudzinski’s sign is tested by flexing the client’s neck and observing for an involuntary flexion of the hips and knees, which suggests meningeal irritation.
B. Ask the client to extend both arms above their head is incorrect; this is not part of the test for Brudzinski’s sign.
C. Place the client in a supine position is correct because the test must be done with the client lying flat on their back.
D. The nurse will place a hand behind the client’s head is correct because the nurse gently lifts the client’s head to assess for involuntary hip and knee flexion.
E. Assist the client to bend their knee 90 degrees is incorrect; knee bending is not required for Brudzinski’s sign but is part of Kernig’s sign testing.
Correct Answer is C
Explanation
A. Epinephrine 1 mg IV
Epinephrine is used for severe anaphylaxis. This reaction is more consistent with a mild allergic (febrile) transfusion reaction, which does not require epinephrine.
B. Acetaminophen 650 mg PO
Acetaminophen is used for febrile reactions but does not treat the allergic symptoms (itching, urticaria).
C. Diphenhydramine 50 mg IV
Diphenhydramine (Benadryl) is given to treat mild allergic transfusion reactions such as flushing, itching, and urticaria.
D. Furosemide 40 mg PO
Furosemide (Lasix) is given between blood transfusions to prevent fluid overload, not for allergic reactions.
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