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 B

Explanation

A. Provide the daughter and client with nutritional counseling.

While nutrition is important, assessing for abuse is the priority.

B. Interview the client alone and assess for abuse.

The client’s reluctance and daughter’s interruptions suggest potential elder abuse.

C. Take the history from the daughter due to the client’s confusion.

The client should be interviewed alone first.

D. Request a psychiatric evaluation.

Confusion can result from dehydration or trauma, not necessarily a psychiatric disorder.

A. Deep purple erythema B. Facial nerve deficits C. Dysphonia or dysphagia D. Heart rate of 10 and blood pressure of 96/68

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.

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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

Correct Answer is B

Explanation

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

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