What is the first priority when caring for a client with a gunshot wound to the chest?

Correct Answer: C

Rationale: The correct answer is C: Apply an airtight dressing. This is the first priority because it helps prevent air from entering the chest cavity, which can cause a tension pneumothorax. A tension pneumothorax can rapidly lead to respiratory distress and cardiac arrest. Applying an airtight dressing helps stabilize the condition until further medical intervention can be provided. Incorrect choices: A: Performing needle decompression is not the first priority as it is indicated for a tension pneumothorax once it has developed, not as a preventive measure. B: Applying a sterile dressing is important but not the first priority when dealing with a gunshot wound to the chest as sealing the wound to prevent air entry is more critical. D: Monitoring the client's ECG is not the first priority in this situation as addressing the potential tension pneumothorax takes precedence over monitoring the client's heart rhythm.

Correct Answer: A

Rationale: The correct answer is A: Use a numeric pain scale. This method allows for quantitative assessment of pain intensity, aiding in accurate pain management. It is widely used in healthcare settings, providing a standardized way to communicate and monitor pain levels. Visual analog scale (B) is subjective and less precise than numeric scales. Facial expression scale (C) may be influenced by cultural factors and is subjective. Observing for signs of depression (D) is important but not specific to assessing pain intensity.

Correct Answer: B

Rationale: The correct answer is B: Provide IV fluids. The first step in caring for a client with severe burn injuries is to ensure adequate hydration and prevent hypovolemic shock. IV fluids are crucial to replace lost fluids and maintain circulation. Cooling the burn site (choice A) may be important but not the first step. Providing pain relief (choice C) is important but not as critical initially. Initiating IV fluids (choice D) is similar to the correct answer, but providing IV fluids is more urgent than initiating them.

Correct Answer: B

Rationale: Step 1: Increasing potassium intake helps lower blood pressure by counteracting the effects of sodium. Step 2: Potassium helps relax blood vessel walls, reducing blood pressure. Step 3: Adequate potassium intake also helps the body balance fluids and maintain normal blood pressure. Summary: A - Increasing sodium intake is counterproductive for hypertension. C - Limiting caffeine helps, but not as directly as increasing potassium. D - Fruits and vegetables are important for a heart-healthy diet and should not be reduced.

Correct Answer: B

Rationale: The correct answer is B: not pulling to a standing position. In an 11-12-month-old child, the inability to pull to a standing position may indicate developmental dysplasia of the hip (DDH) as it can lead to abnormal hip development. Refusal to walk (A) can be a sign of other musculoskeletal issues but not specific to DDH. Negative Trendelenburg sign (C) refers to weakness in the hip abductors and is not a specific finding for DDH. A negative Ortolani sign (D) indicates the absence of hip dislocation and is not a definitive sign of DDH at this age.

Correct Answer: C

Rationale: The correct answer is C: Administer aspirin. Aspirin should be administered first to prevent further clot formation and reduce the risk of recurrent stroke. Monitoring blood pressure (A) is important but not the first priority. Administering IV fluids (B) is not necessary unless indicated. Applying a warm compress (D) is not a priority in the acute management of a stroke. Administering aspirin promptly can significantly impact the client's outcome by preventing further clot formation.

Correct Answer: C

Rationale: Step 1: Hypertension is often worsened by high sodium intake. Step 2: Decreasing sodium intake helps lower blood pressure. Step 3: This dietary change aligns with hypertension management. Step 4: Increasing processed foods (A), saturated fats (D), or potassium intake (B) do not directly address the issue of high sodium intake and may even exacerbate hypertension.

Correct Answer: B

Rationale: The correct answer is B because taking insulin only when blood sugar is high is incorrect and can lead to dangerous complications. Step 1: Insulin should be taken as prescribed by the healthcare provider, not based solely on blood sugar levels. Step 2: Checking blood sugar regularly (A) is essential for diabetes management. Step 3: Eating a balanced diet and exercising regularly (C) are crucial for diabetes control. Step 4: Reporting signs of infection to the healthcare provider (D) is important due to diabetes-related complications.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. Dehydration and hypotension indicate fluid loss, which can lead to organ damage and shock. Administering IV fluids helps restore blood volume and improve blood pressure. Monitoring blood pressure (B) is important but addressing the underlying issue of fluid loss is crucial. Administering antihypertensive medications (C) would further lower blood pressure, worsening hypotension. Administering diuretics (D) would exacerbate fluid loss, worsening dehydration and hypotension.