What is the first priority of the treatment for a client with tension pneumothorax?

Relieve increased intrapleural pressure

Relieve increased intracranial pressure

Cover wound with occlusive dressing

Decrease cardiac output

Answer and Explanation

The Correct Answer is A

A. Relieve increased intrapleural pressure: The primary life-threatening issue in tension pneumothorax is the buildup of pressure in the pleural space, which compresses the lungs and great vessels. Immediate decompression (e.g., needle thoracostomy) restores ventilation and venous return, preventing cardiovascular collapse.

B. Relieve increased intracranial pressure: Intracranial pressure is unrelated to tension pneumothorax. Interventions targeting ICP do not address the acute respiratory and circulatory compromise in this situation.

C. Cover wound with occlusive dressing: This may be appropriate for an open (sucking) chest wound, but in tension pneumothorax, the critical problem is trapped air, not just an open wound. Occlusive dressing alone does not relieve the intrapleural pressure.

D. Decrease cardiac output: Cardiac output is already compromised by the increased intrathoracic pressure. Reducing it further would worsen shock. The priority is to restore perfusion, not decrease cardiac output.

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Correct Answer is C

Explanation

A. Inverted P wave: An inverted P wave may indicate an ectopic atrial rhythm, but it is usually not an immediate life-threatening finding and does not require urgent intervention in the context of chest pain.

B. Sinus tachycardia: Sinus tachycardia can be a response to pain, anxiety, or hypovolemia. While it should be monitored, it is less specific for myocardial ischemia or infarction and is not the priority finding to report immediately.

C. ST segment elevation: ST segment elevation is a hallmark sign of acute myocardial injury or infarction. Immediate reporting to the healthcare provider is critical, as timely intervention can prevent myocardial damage and reduce morbidity and mortality.

D. Frequent premature atrial contractions (PACs): PACs are common and often benign. They may require monitoring, but they are not as urgent as ST segment changes in a client presenting with chest pain.

A. To prevent aspiration of stomach contents B. To prevent flexion contractures C. To decrease cerebral perfusion pressure D. To avoid impeding venous outflow

Correct Answer is D

Explanation

A. To prevent aspiration of stomach contents: Elevating the head of the bed can help reduce aspiration risk, but in the context of a head injury, the primary concern is not gastrointestinal; this does not fully explain the combination of head and hip positioning.

B. To prevent flexion contractures: Avoiding sharp hip flexion helps prevent contractures, but the directive to maintain the head in neutral alignment is unrelated to musculoskeletal contracture prevention, so this does not encompass all prescribed measures.

C. To decrease cerebral perfusion pressure: Interventions like HOB elevation and neutral head position do not decrease cerebral perfusion pressure intentionally; the goal is to optimize cerebral blood flow while managing intracranial pressure, not to lower perfusion.

D. To avoid impeding venous outflow: Elevating the HOB, maintaining neutral head alignment, and avoiding sharp hip flexion prevent obstruction of venous return from the brain. This promotes cerebral venous drainage, reduces intracranial pressure, and helps prevent secondary brain injury, making it the primary rationale for these orders.

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What is the first priority of the treatment for a client with tension pneumothorax?

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Naxlex Comprehensive Predictor Exams

Which electrocardiographic (ECG) change is most important for the nurse to communicate to the health care provider when caring for a client with chest pain?

Correct Answer is C

Explanation

What is the best rationale for the following health care provider prescriptions for a client with a head injury: elevate the HOB: keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion?

Correct Answer is D

Explanation

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