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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A chylothorax refers to the accumulation of chyle, a milky, lymphatic fluid, in the pleural space. This typically results from disruption of the thoracic duct, often due to trauma or malignancy. The fluid's characteristic milky appearance is due to its high triglyceride content, not a pus-like consistency.
Choice B rationale
A pneumothorax is the presence of air in the pleural space, leading to lung collapse. It is characterized by respiratory distress and diminished breath sounds, not the presence of fluid with a pus-like appearance. This condition involves gas, not liquid, accumulation in the pleural cavity.
Choice C rationale
A hemothorax is the accumulation of blood in the pleural space, usually due to trauma or a ruptured blood vessel. The fluid would appear bloody, not pus-like. While blood can become infected, a primary hemothorax itself presents as serosanguineous or frank blood, differing from purulent exudate.
Choice D rationale
Empyema refers to the accumulation of pus in the pleural space, most commonly caused by bacterial infection. The pus-like appearance of the drained fluid is a direct indication of a significant inflammatory and infectious process, where leukocytes, necrotic debris, and microorganisms are present, forming purulent exudate.
Correct Answer is B
Explanation
Choice A rationale
Respiratory acidosis is characterized by a low pH and an elevated PaCO2. The patient's pH is elevated (7.61), indicating alkalosis, and the PaCO2 is low (22 mmHg). These findings are the opposite of what would be seen in respiratory acidosis.
Choice B rationale
The pH of 7.61 is significantly elevated, indicating alkalosis. The PaCO2 of 22 mmHg is markedly decreased below the normal range (35-45 mmHg). This decrease in carbon dioxide, a potent acid, directly causes the alkalosis. The bicarbonate (HCO3) level of 25 mEq/L is within the normal range (22-26 mEq/L), indicating that the renal system has not yet initiated any compensatory response. Therefore, this pattern is consistent with uncompensated respiratory alkalosis, primarily driven by hyperventilation.
Choice C rationale
Metabolic alkalosis would present with an elevated pH and an elevated bicarbonate level. While the pH is elevated, the bicarbonate (25 mEq/L) is within the normal range, and the PaCO2 is low, which is inconsistent with metabolic alkalosis as the primary imbalance.
Choice D rationale
Metabolic acidosis is characterized by a low pH and a low bicarbonate level. The patient's pH is high (alkalotic) and the bicarbonate is normal. This contradicts the diagnostic criteria for metabolic acidosis.
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