A nurse in the Emergency Department is assessing a client who was in a motor vehicle crash.
Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 116/68, HR 124, RR 38, Temp 101.4 degrees F, SpO2 92% on room air. Which of the following actions should the nurse take first?
Administer oxygen via a high-flow (Non-rebreather) mask.
Obtain a chest X-ray.
Prepare for chest tube insertion.
Initiate IV access.
The Correct Answer is A
Choice A rationale
Administering oxygen via a high-flow (Non-rebreather) mask is the immediate priority due to the client's hypoxemia, indicated by an SpO2 of 92% on room air. This action directly addresses the life-threatening compromise in oxygenation, increasing the fraction of inspired oxygen (FiO2) and improving tissue perfusion. Adequate oxygenation is critical to prevent further cellular damage and organ dysfunction in an acute respiratory distress scenario. Normal SpO2 is 95-100%.
Choice B rationale
Obtaining a chest X-ray is an important diagnostic step to identify the underlying cause of absent breath sounds, such as a pneumothorax or hemothorax. However, it is not the *first* action because stabilizing the client's oxygenation and ventilation takes precedence. While imaging provides crucial information, delaying oxygen administration to perform an X-ray could worsen the client's respiratory compromise.
Choice C rationale
Preparing for chest tube insertion is a critical intervention for conditions like pneumothorax or hemothorax, which are suggested by absent breath sounds. While this may be necessary, it is a definitive treatment that follows initial stabilization. Ensuring adequate oxygenation and establishing a clear diagnosis are prerequisites before proceeding with an invasive procedure like chest tube insertion.
Choice D rationale
Initiating IV access is essential for fluid resuscitation, medication administration, and emergency interventions. However, in the hierarchy of needs for a client with acute respiratory distress, establishing an airway and ensuring adequate oxygenation are paramount. While IV access should be established promptly, it does not supersede the immediate need to address life-threatening hypoxemia.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While establishing IV access and fluid replacement are crucial in trauma, they are secondary to ensuring cervical spine stabilization in a patient who is unresponsive after a head-on motor vehicle crash. Uncontrolled movement of an unstable cervical spine can lead to irreversible spinal cord injury, exacerbating neurological deficits or causing paralysis.
Choice B rationale
Monitoring pulse and blood pressure frequently is an important ongoing assessment in a trauma patient to identify shock or other systemic issues. However, in the immediate post-crash scenario with an unresponsive patient, the primary concern is preventing further neurological damage from potential spinal cord injury, making stabilization a higher priority.
Choice C rationale
Inserting a nasogastric tube for decompression might be necessary later in the management of a trauma patient to prevent aspiration or gastric distension. However, it is not the immediate priority action in an unresponsive patient following a head-on collision, where airway, breathing, circulation, and most importantly, cervical spine protection are paramount.
Choice D rationale
In an unresponsive client following a head-on motor vehicle crash, cervical spine injury must be presumed until ruled out. Any movement of the head or neck could further compromise the spinal cord, leading to permanent neurological deficits or even death. Therefore, keeping the neck stabilized using a cervical collar and backboard is the absolute priority to prevent further injury.
Correct Answer is A
Explanation
Choice A rationale
Normal arterial blood gas (ABG) values are pH 7.35-7.45, $PaCO_2$ 35-45 mmHg, and $HCO_3^-$ 22-26 mEq/L. Olivia's ABG results of pH 7.40, $PaCO_2$ 40 mmHg, and $HCO_3^-$ 24 mEq/L all fall within these normal physiological ranges, indicating no acid-base imbalance despite her anxiety and hyperventilation episode.
Choice B rationale
Intubation is a medical procedure to secure an airway, typically for respiratory failure or severe oxygenation/ventilation issues. Olivia's ABG results are completely normal, indicating effective gas exchange and no respiratory distress requiring intubation. There is no physiological basis in these ABG numbers to warrant such an invasive intervention.
Choice C rationale
Inconclusive results suggest that the data gathered is insufficient or ambiguous to draw a definitive conclusion. However, Olivia's ABG results are clearly within normal physiological parameters. The values are precise and fall squarely within the reference ranges, making them conclusive for normal acid-base status.
Choice D rationale
Partial compensation in acid-base balance occurs when the body's compensatory mechanisms are actively trying to correct a primary imbalance but have not fully restored the pH to normal. Since Olivia's pH, $PaCO_2$, and $HCO_3^-$ are all within normal limits, there is no primary imbalance for which the body needs to compensate, thus ruling out partial compensation. .
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