A patient is brought to the Emergency Department with a gunshot wound to the chest. The healthcare professional assesses an abnormality involving a pleural rupture that acts as a one-way valve, permitting air to enter on inspiration but preventing its escape by closing during expiraton. What action by the healthcare professional is the priority?
Assist with a chest tube insertion
Give the patient low-flow oxygen
Assess for clubbing of fingernails
Draw arterial gases
The Correct Answer is A
A. Assist with a chest tube insertion: A gunshot wound to the chest with a one-way valve pleural rupture indicates a tension pneumothorax, a life-threatening condition. Air enters the pleural space with each breath but cannot escape, leading to increased intrathoracic pressure, lung collapse, and mediastinal shift, which can compromise venous return and cardiac output. Immediate chest tube insertion or needle decompression is necessary to relieve pressure and restore normal lung function.
B. Give the patient low-flow oxygen: Oxygen therapy may help improve oxygenation, but it does not address the underlying issue of trapped air causing intrathoracic pressure buildup. Without intervention to release the trapped air, respiratory distress and cardiovascular collapse can occur.
C. Assess for clubbing of fingernails: Clubbing is a sign of chronic hypoxia seen in long-term respiratory diseases but is not relevant in the acute management of a tension pneumothorax. The priority is to relieve the trapped air and restore normal lung expansion.
D. Draw arterial gases: While arterial blood gases can help assess oxygenation and ventilation status, they do not treat the underlying tension pneumothorax. Immediate decompression is required before diagnostic tests to prevent rapid deterioration and potential cardiac arrest.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Hypoventilation causes hypocapnia: Hypoventilation leads to inadequate removal of carbon dioxide (CO₂), resulting in hypercapnia rather than hypocapnia. This occurs because decreased ventilation reduces gas exchange efficiency, allowing CO₂ to accumulate in the blood, which can cause respiratory acidosis.
B. Hypoventilation causes alkalosis: Hypoventilation leads to respiratory acidosis rather than alkalosis. When ventilation is insufficient, CO₂ builds up in the bloodstream, leading to an increase in hydrogen ion concentration and a subsequent drop in blood pH. This is commonly seen in conditions like chronic obstructive pulmonary disease (COPD), neuromuscular disorders, and opioid overdose.
C. Hyperventilation causes acidosis: Hyperventilation results in excessive elimination of CO₂, leading to a decrease in hydrogen ion concentration and an increase in blood pH, causing respiratory alkalosis rather than acidosis. Acidosis occurs when CO₂ retention leads to an increase in hydrogen ion concentration, which is the opposite of what happens with hyperventilation.
D. Hyperventilation causes hypocapnia: Hyperventilation leads to an excessive exhalation of CO₂, causing a reduction in blood CO₂ levels (hypocapnia). This can result in respiratory alkalosis, leading to symptoms such as dizziness, lightheadedness, tingling sensations, and even syncope. It is often seen in conditions like anxiety, panic attacks, fever, or high-altitude exposure.
Correct Answer is C
Explanation
A. Prolonged PR interval: A prolonged PR interval is typically indicative of first-degree atrioventricular (AV) block and does not specifically relate to the presence of myocardial infarction (MI) that extends through the myocardium.
B. ST depression: ST depression can indicate subendocardial ischemia, but it is not a definitive change associated with a full-thickness myocardial infarction. It is more commonly seen during stress testing or in cases of angina rather than a transmural infarction.
C. ST elevation: ST elevation is a characteristic finding in cases of transmural myocardial infarction (MI), indicating that the injury extends through the myocardium from the endocardium to the epicardium. This elevation occurs due to the acute injury to the myocardial cells, leading to changes in the electrical activity as reflected on the ECG.
D. Prolonged QT interval: A prolonged QT interval is associated with an increased risk of arrhythmias but does not specifically indicate a myocardial infarction that penetrates through the myocardium. It is generally not directly related to the ischemic process of an MI.
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