The nurse is caring for a client who has suffered a gunshot wound to the anterior chest. The client has been intubated and is currently being ventilated with a bag-valve device. What is the priority intervention for this client now?

Assessment of neurologic status

Obtain IV access with two large bore lines and blood for lab studies

Placement of a naso-gastric tube to decompress the stomach

Placement of an indwelling catheter (Foley) to measure urine output

Answer and Explanation

The Correct Answer is B

A. Assessment of neurologic status
While neurological assessment is important, it is not the priority in this situation. The immediate priority is managing the chest wound and airway to ensure oxygenation and prevent further complications.

B. Obtain IV access with two large bore lines and blood for lab studies
IV access is important for fluid resuscitation and medication administration but is not the immediate priority compared to securing the airway and ensuring ventilation.

C. Placement of a naso-gastric tube to decompress the stomach
Although the naso-gastric tube may be necessary to decompress the stomach later, it is not the priority in the initial management of a client with a gunshot wound to the chest.

D. Placement of an indwelling catheter (Foley) to measure urine output
While measuring urine output is important for monitoring renal function and fluid balance, it is not the priority in this emergency situation.

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Correct Answer is C

Explanation

A. Deep purple erythema

This suggests bruising or possible hematoma formation, which is concerning but may not be immediately life-threatening.

B. Facial nerve deficits

This indicates nerve injury, which is serious but may not be immediately life-threatening.

C. Dysphonia or dysphagia

Dysphonia (difficulty speaking) or dysphagia (difficulty swallowing) are signs of airway compromise or injury to structures involved in breathing and swallowing. This requires immediate attention.

D. Heart rate of 100 and blood pressure of 96/68

These vital signs indicate tachycardia and borderline hypotension, which are concerning, but the airway compromise (option C) is more immediately life-threatening.

A. 63% TBSA B. 45% TBSA C. 36% TBSA D. 27% TBSA

Correct Answer is C

Explanation

A. 63% TBSA
This value is too high based on the Rule of Nines calculation.

B. 45% TBSA
This overestimates the burn area.

C. 36% TBSA
Using the Rule of Nines, the TBSA is calculated as follows:

Entire right arm (anterior + posterior): 9%
Posterior trunk: 18%
Posterior right leg: 9%
Total TBSA = 9% + 18% + 9% = 36%

D. 27% TBSA
This underestimates the affected areas.

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The nurse is caring for a client who has suffered a gunshot wound to the anterior chest. The client has been intubated and is currently being ventilated with a bag-valve device. What is the priority intervention for this client now?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who received a blunt force injury to zone II of the neck. Which assessment finding should the nurse report to the physician IMMEDIATELY?

Correct Answer is C

Explanation

The nurse is caring for an adult with a burn injury. The following parts of the patient's body were burned: anterior and posterior right arm, posterior trunk. and posterior right leg. Using the Rule of Nines, calculate the Total Body Surface Area (TBSA) percentage that is involved.

Correct Answer is C

Explanation

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