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: Administer epinephrine. Epinephrine is the first-line treatment for anaphylaxis as it quickly reverses severe allergic reactions. It works by constricting blood vessels, relaxing airway muscles, and increasing heart rate. These actions help to counteract the potentially life-threatening symptoms of anaphylaxis, such as difficulty breathing and a drop in blood pressure. Applying antihistamines (B) may help with mild allergic reactions but are not sufficient for anaphylaxis. Administering morphine (C) or pain relief (D) is not appropriate initially as they do not address the immediate life-threatening nature of anaphylaxis.

Correct Answer: A

Rationale: The correct answer is A: Administer anticoagulants. This is crucial for preventing blood clots post-surgery as they help thin the blood and reduce clot formation. Monitoring for arrhythmias (B) is important but not the priority in this case. While encouraging deep breathing (C) and fluid intake (D) are beneficial for post-surgical recovery, they do not directly address the risk of blood clot formation. Administering anticoagulants is the most effective intervention to prevent blood clots in high-risk surgical patients.

Correct Answer: B

Rationale: The correct answer is B: Place the client in a supine position. This is the first step when administering Heparin to prevent bleeding or bruising at the injection site. Placing the client in a supine position helps reduce the risk of injury and promotes optimal absorption. Administering antipyretics (Choice A) is not the first step in administering Heparin. Administering insulin (Choice C) is unrelated to Heparin administration. Monitoring vital signs (Choice D) is important but typically done after the initial step of positioning the client correctly.

Correct Answer: B

Rationale: Step 1: Administering IV antibiotics is important for treating infections, but in this case, the focus is on addressing the pain associated with the deep wound infection. Step 2: Administering pain relief helps improve the client's comfort and quality of life while the infection is being treated. Step 3: Changing the dressing is essential for wound care but does not directly address the client's pain from the infection. Step 4: Performing a CT scan may be necessary to assess the extent of the infection, but it does not directly provide immediate relief for the client's pain. Summary: Administering pain relief is the most appropriate intervention as it directly addresses the client's symptoms and improves their comfort level during the treatment of the deep wound infection.