A nurse in the emergency department is assessing a patient who was in a motor vehicle crash.
Findings include absent breath sounds in the left lower lobe with dyspnea, BP 118/68 mmHg, heart rate 124 bpm, respirations 38 breaths/min, temperature 38.6 °C, and oxygen saturation 90%. Which of the following actions should the nurse do first?
Initiate IV access.
Obtain a chest X-ray.
Administer oxygen via high-flow mask.
Prepare for chest tube insertion.
The Correct Answer is C
Choice A rationale
While IV access is important for fluid resuscitation and medication administration, establishing an airway and ensuring adequate oxygenation are the most immediate priorities. The patient's oxygen saturation is critically low at 90%, indicating severe hypoxemia. Following the ABCs of resuscitation (Airway, Breathing, Circulation), addressing the breathing problem takes precedence over initiating an IV line.
Choice B rationale
A chest X-ray is a diagnostic tool that provides crucial information about the underlying pathology, such as a pneumothorax. However, obtaining a chest X-ray takes time and should not delay immediate, life-saving interventions. The patient's respiratory distress and low oxygen saturation require immediate action to support oxygenation, as delayed intervention can lead to respiratory failure and cardiac arrest.
Choice C rationale
The patient's respiratory rate of 38 breaths/min and oxygen saturation of 90% indicate severe respiratory distress and hypoxemia. Administering high-flow oxygen directly addresses the life-threatening lack of oxygen, improving tissue oxygenation and supporting cellular function. This is the most critical first step in managing a patient with compromised breathing, following the ABCs of resuscitation.
Choice D rationale
Preparing for a chest tube insertion is a vital intervention for a suspected pneumothorax, which is suggested by the absent breath sounds. However, this is a procedural step that follows the initial stabilization of the patient's breathing. The immediate priority is to provide oxygen to prevent further desaturation, while simultaneously preparing for definitive treatment. The preparation should happen concurrently with oxygen administration, not before it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Administering heparin via IV infusion is an important long-term treatment for a pulmonary embolism but is not the immediate priority. Heparin is an anticoagulant that prevents the formation of new clots and the enlargement of existing ones. However, the most life-threatening issue for this patient is hypoxemia due to impaired gas exchange. The immediate priority must be to address the patient's acute respiratory distress and stabilize their oxygen saturation.
Choice B rationale
Administering oxygen therapy is the priority nursing action for a patient with suspected pulmonary embolism. The patient's symptoms of acute dyspnea and rapid respirations (38 breaths/min, normal range is 12-20 breaths/min) indicate significant respiratory compromise and hypoxemia. Supplying supplemental oxygen directly addresses the ventilation-perfusion mismatch and improves tissue oxygenation, which is the most critical and life-threatening issue.
Choice C rationale
Obtaining a spiral CT scan is a diagnostic test to confirm a pulmonary embolism. While this is a critical step in the diagnostic pathway, it is not the immediate priority nursing action. The patient is showing signs of acute respiratory distress and physiological instability. The nurse must first stabilize the patient's oxygenation and vital signs before any further diagnostic procedures can be safely performed. Patient stabilization precedes definitive diagnosis.
Choice D rationale
Notifying the provider is an essential step in the management of a pulmonary embolism, but it is not the absolute priority. The patient's vital signs and acute symptoms (heart rate 117 bpm, respirations 38 breaths/min) indicate an unstable state that requires immediate intervention. The nurse should initiate life-saving actions, such as oxygen therapy, to stabilize the patient's condition before or while notifying the provider of the emergent situation.
Correct Answer is D
Explanation
Choice A rationale
Flail chest is the paradoxical movement of a section of the chest wall, caused by multiple rib fractures in two or more places. It is characterized by paradoxical chest wall motion, where the injured segment moves in during inspiration and out during expiration. While it is a severe chest injury, it does not typically involve a large accumulation of blood in the pleural space, which is the defining characteristic mentioned in the patient's presentation.
Choice B rationale
A tension pneumothorax is a life-threatening condition where air enters the pleural space but cannot exit, causing a rapid increase in intrathoracic pressure. This leads to tracheal deviation, hypotension, and profound respiratory distress. While it can cause a collapsed lung and dyspnea, the defining characteristic is air trapping, not blood accumulation in the pleural space, making this diagnosis inconsistent with the patient's specific presentation of hemothorax.
Choice C rationale
A simple pneumothorax is the presence of air in the pleural space, causing the lung to collapse, but without the one-way valve effect seen in a tension pneumothorax. It presents with dyspnea and asymmetrical chest expansion. While it causes a collapsed lung, the defining feature of this patient's case is the presence of a blood accumulation in the pleural space, which is not a hallmark of a simple pneumothorax.
Choice D rationale
A hemothorax is a medical condition characterized by the accumulation of blood in the pleural cavity, which is the space between the lungs and the chest wall. The presence of a collapsed lung, blood accumulation in the pleural space, dyspnea, and asymmetrical chest expansion directly corresponds to the classic presentation of a hemothorax. This diagnosis accurately and completely accounts for all the symptoms described in the patient's clinical scenario. .
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