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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Laterally on the left side
Lateral positioning may not fully prevent contractures.
B. Supine with a pillow under the head
A pillow under the head can cause neck contractures.
C. Semi-Fowler’s without a pillow, right arm & hand elevated
Prevents contractures and promotes drainage of edema.
D. Prone without a pillow
Prone position increases discomfort and risk of respiratory complications.
Correct Answer is D
Explanation
A. Continue to monitor the client as a paralytic ileus is possible
Paralytic ileus can occur postoperatively, but sudden severe pain and distension indicate a more serious issue, such as bowel infarction.
B. Administer the PRN stool softener to the client
A stool softener is inappropriate if the client has a possible bowel obstruction or ischemia.
C. Obtain an order to insert a nasogastric tube set to low suction
An NG tube may help relieve distension, but it does not treat the underlying cause. The priority is to notify the surgeon.
D. Report the assessment findings to the surgeon
Absent bowel sounds, severe pain, and distension suggest bowel ischemia, a life-threatening complication requiring immediate surgical intervention.
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