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 A
Explanation
A. Prinzmetal or variant angina: Prinzmetal angina, also known as variant angina, is characterized by episodes of chest pain due to vasospasms of the coronary arteries. This type of angina can occur unpredictably, often at rest, and is associated with transient ischemia of the heart muscle.
B. Unstable angina: Unstable angina is characterized by sudden, unpredictable chest pain that occurs at rest or with minimal exertion and may last longer than stable angina. It indicates a significant risk of myocardial infarction but is not primarily caused by vasospasm.
C. Angina pectoris: Angina pectoris is a general term for chest pain due to ischemia, which can be stable or unstable. It does not specifically refer to the vasospasm that defines Prinzmetal angina.
D. Stable angina: Stable angina is characterized by predictable chest pain that occurs with exertion or stress and is relieved by rest or nitroglycerin. It is not associated with coronary artery vasospasms.
Correct Answer is D
Explanation
A. Inflammation: Inflammation refers to the body's immune response to injury or infection and does not specifically denote a temporary deprivation of blood supply to a cell. It is characterized by redness, swelling, heat, and pain in the affected area.
B. Necrosis: Necrosis is the process of cell death that occurs when cells are irreversibly damaged, often due to a lack of blood supply or other injury. It is a consequence of prolonged ischemia rather than the temporary condition itself.
C. Infarction: Infarction refers to the death of tissue due to prolonged ischemia, resulting from an irreversible loss of blood supply. It indicates permanent damage and is not synonymous with a temporary deprivation of blood supply.
D. Ischemia: Ischemia is the term used to describe a temporary reduction in blood flow to a tissue or organ, resulting in a deficiency of oxygen and nutrients. This condition can lead to symptoms and may cause damage if prolonged, making it the correct answer for this scenario.
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