A patient has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?
Apply oxygen at 100%.
Assess the heart rate.
Ensure a patent airway.
Start two large-bore IV lines.
The Correct Answer is C
Choice A reason:
Applying oxygen at 100% is an important step in managing a patient with a life-threatening chest injury. However, ensuring a patent airway is the first priority, as it is crucial to maintain airway patency to facilitate oxygen delivery. Without an open airway, oxygen administration would be ineffective.
Choice B reason:
Assessing the heart rate is part of the initial assessment in emergency care. However, the priority is to ensure a patent airway, as a compromised airway can lead to hypoxia and rapid deterioration of the patient's condition. Heart rate assessment can follow once airway patency is confirmed.
Choice C reason:
Ensuring a patent airway is the top priority in the emergency management of a patient with a life-threatening chest injury. Airway patency is essential for effective ventilation and oxygenation. If the airway is obstructed, the patient cannot receive oxygen or expel carbon dioxide, leading to life-threatening complications.
Choice D reason:
Starting two large-bore IV lines is important for fluid resuscitation and medication administration. However, the primary focus should be on ensuring a patent airway, as immediate airway management is critical to the patient's survival in the acute phase of a life-threatening chest injury.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
Choice A reason:
Autonomic dysreflexia is a serious condition that can occur in individuals with spinal cord injuries, particularly those at or above the T6 level. It is a secondary injury mechanism that results from the autonomic nervous system's abnormal response to stimuli below the level of injury, leading to severe hypertension and other complications.
Choice B reason:
Ischemia, or reduced blood flow, is a common cause of secondary injury following a spinal cord injury. It can result from initial trauma or subsequent swelling and vascular damage, leading to further cell death and tissue damage.
Choice C reason:
Edema, or swelling, is another cause of secondary injury in spinal cord injuries. The inflammatory response to injury can cause fluid accumulation, increasing pressure within the spinal column and exacerbating damage to spinal cord tissues.
Choice D reason:
Axial loading is a primary mechanism of spinal cord injury, not a secondary injury cause. It refers to the vertical force applied along the axis of the spine, typically resulting from falls or direct blows, leading to compression and potential fractures.
Choice E reason:
Hemorrhage, or bleeding, is a significant cause of secondary injury in spinal cord trauma. It can result from blood vessel damage at the injury site, leading to increased pressure, further tissue damage, and impaired blood flow.
Correct Answer is A
Explanation
Choice A reason:
A heart rate of 45 beats/min (bradycardia) is concerning because it indicates a significant impact on the autonomic nervous system, which can occur with high thoracic spinal cord injuries. Bradycardia can lead to inadequate cardiac output and may require immediate intervention to prevent further cardiovascular compromise.
Choice B reason:
An SpO2 of 91% is slightly below normal but not immediately life-threatening. While monitoring and addressing oxygen saturation is important, it is not as critical as the hemodynamic instability indicated by bradycardia in this context.
Choice C reason:
A blood pressure of 98/62 mmHg is on the lower end of the normal range but not immediately alarming. While hypotension is a concern in spinal cord injury patients, the more pressing issue in this scenario is the bradycardia, which can have more immediate and severe consequences.
Choice D reason:
Loss of motor and sensory function in the extremities is a significant finding in spinal cord injuries and indicates the level and severity of the injury. However, it is not immediately life-threatening and does not require as urgent intervention as bradycardia in this acute setting.
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