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Auscultate bowel sounds, record the findings, and obtain a 12-lead ECGWhile auscultating bowel sounds can help assess for bowel injury and an ECG is useful for monitoring cardiac function, these interventions are not the priority. The client is in shock and requires immediate intervention to restore perfusion.

Initiate the standing prescription for Dopamine at 16 mcg/kg/minuteDopamine can be used to support blood pressure in shock, but fluid resuscitation is the first-line intervention in hypovolemic shock. Vasopressors like dopamine are typically added after fluid resuscitation if hypotension persists.

Place soft restraints on the upper extremities and sedate as necessaryThe client's restlessness is likely due to hypoxia and inadequate perfusion, not agitation. Restraints and sedation would delay critical interventions and could worsen hemodynamic instability.

includes the head-to-toe anterior and posterior assessment. This describes a secondary assessment, not a primary one. The primary assessment focuses on the immediate life-threatening issues rather than a full head-to-toe examination.

priorities are continuing and ongoing but treatment will be deferred if the client is unstable.In primary assessment, treatment should not be deferred in unstable clients. Immediate treatment and stabilization take priority.

is focused on airway maintenance and ventilation effectiveness.As airway and ventilation are key aspects of the primary assessment (known as the "ABC" of trauma: Airway, Breathing, Circulation). However, it does not cover all of the primary assessment areas.

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.

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.

Placement of an indwelling catheter (Foley) to measure urine outputWhile measuring urine output is important for monitoring renal function and fluid balance, it is not the priority in this emergency situation.

is expected to be decreased for three to five days.In the initial stages following severe burn injury, there is often oliguria (low urine output), but this is typically followed by diuresis (increased urine output) after the first 24-48 hours, not a decrease over 3-5 days.

output will be greatest in the first 24 hours after the burn injury.Although urine output may increase with proper fluid resuscitation, it is not usually greatest in the first 24 hours; the increase typically happens after the initial resuscitation period.

will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment.While fluid resuscitation leads to an increase in urine output after the first 24-48 hours, it is not expected to be elevated right away. The kidneys may initially respond with oliguria.

Avoid using an electric razor This is not directly relevant to trigeminal neuralgia management. Although it may be important for clients to avoid stimulating the face in general, an electric razor is not a specific concern for trigeminal neuralgia.

Meats should be served hotHot foods should actually be avoided, as extreme temperatures can trigger trigeminal neuralgia pain. Therefore, this recommendation is incorrect.

Teeth should be brushed prior to each meal This is a reasonable recommendation for maintaining oral hygiene, but it does not specifically address managing trigeminal neuralgia pain. It is not as effective as the correct measure for managing trigeminal neuralgia.

Removal of the educating patient to carry an Epipen While educating the patient about carrying an Epipen is essential in managing anaphylaxis, it is not the primary action in preventing anaphylactic shock before exposure to an allergen.

Administer diphenhydramine and solumedrol IV at the first sign of allergic symptomsThese medications help in managing allergic reactions but do not prevent anaphylactic shock. Preventive measures focus on avoiding allergen exposure rather than treating symptoms after they occur.

Application of a red allergy bracelet on the patient’s upper extremityThis helps alert healthcare providers about allergies, but it does not prevent anaphylactic shock. It is a precautionary step rather than a primary prevention strategy.

Prepare for immediate surgery to repair the open fracture Surgery may be necessary, but it is not the immediate priority. The focus should be on stabilizing the client and preventing further injury.

Assess for pulses in the upper and lower extremities Assessing circulation is important but is not the most immediate life-saving intervention. First, the client must be stabilized and bleeding controlled.

Place a sterile pressure dressing on the open fracture While controlling bleeding is important, spinal immobilization takes precedence in trauma cases to prevent potential spinal cord injury.

Massive blood loss leading to decreased oxygen delivery to tissuesThis describes hypovolemic shock, which occurs due to significant blood or fluid loss (e.g., hemorrhage, severe dehydration). In this scenario, there is no evidence of massive blood loss, making hypovolemic shock unlikely.

Severe allergic reaction causing systemic vasodilation and increased capillary permeabilityThis describes anaphylactic shock, which results from an acute allergic reaction (e.g., to food, medication, insect stings). There is no mention of an allergen exposure or symptoms like wheezing, stridor, or urticaria, making anaphylactic shock unlikely.

Cardiac failure resulting in inadequate tissue perfusion and oxygenationThis describes cardiogenic shock, which occurs due to heart failure (e.g., from myocardial infarction, cardiomyopathy). It leads to low cardiac output, pulmonary congestion, and organ hypoperfusion. This patient’s infection and systemic inflammation suggest septic shock, not a primary cardiac event.