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: D

Rationale: The correct answer is D because it directly asks for specific information about past hospitalizations, prompting Mr. Y to recall the last time he was admitted for chest pain. This question is open-ended, allowing Mr. Y to provide detailed information voluntarily. A is incorrect as it assumes Mr. Y has been hospitalized without directly asking for that information. B is a better choice but lacks specificity in requesting details about past hospitalizations. C is inappropriate as it assumes permission to access medical records without Mr. Y's consent.

Correct Answer: D

Rationale: The correct answer is D because polio, pertussis, and measles are highly infectious diseases that can have severe consequences if not prevented through vaccination. Polio can cause paralysis, pertussis can be fatal in infants, and measles can lead to complications like pneumonia and encephalitis. Emphasizing these vaccines can significantly reduce the risk of outbreaks and protect public health. Choice A is incorrect because HPV and genital herpes are sexually transmitted infections, and although important, they are not typically prevented through vaccines like polio, pertussis, and measles. Choice B is incorrect because pneumonia, HIV, and mumps, while serious diseases, do not have vaccines that are as universally recommended for prevention as polio, pertussis, and measles. Choice C is incorrect because syphilis and gonorrhea are sexually transmitted infections, and pneumonia is not typically prevented through vaccination as effectively as polio, pertussis, and measles.

Correct Answer: B

Rationale: The correct answer is B because building trust with patients is crucial for effective communication and promoting patient cooperation. Trust takes time to develop and is essential in gaining accurate information about a patient's health. Patients may not disclose all information if they do not trust the nurse. Choice A is incorrect because patients may withhold information for various reasons. Choice C is incorrect as not all patients seeking care may fully understand the Canadian health care system. Choice D is incorrect because not all patients may recognize the importance of answering all questions, especially if they are uncomfortable or lack trust in the healthcare provider.

Correct Answer: B

Rationale: The correct answer is B because critical thinking helps nurses analyze complex situations, identify relevant information, and plan effective interventions. It allows for systematic problem-solving and decision-making, leading to optimal patient care outcomes. Choice A is incorrect as critical thinking doesn't guarantee immediate answers. Choice C is incorrect because critical thinking complements clinical guidelines rather than replacing them. Choice D is incorrect as physical assessments are essential in nursing care and critical thinking enhances, not bypasses, this process.

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.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. In respiratory distress, the priority is to ensure adequate oxygenation. Oxygen therapy helps improve oxygen levels in the blood and relieve respiratory distress. Administering diuretics (B) may not address the immediate need for oxygen. Increasing respiratory rate (C) may lead to worsening distress if the underlying cause is not addressed. Administering IV fluids (D) is not the priority unless specifically indicated for the client's condition. It is crucial to prioritize oxygen delivery to support vital functions and stabilize the client's condition.

Correct Answer: B

Rationale: The correct answer is B: Hypertrophic scar. This type of scar is raised, red, and irregular, but it does not extend beyond the boundaries of the original wound like a keloid. A keloid is characterized by excessive scar tissue that grows beyond the wound site. Contracture is a scar that causes tightening of the skin and may restrict movement. Stretch marks, on the other hand, are not raised or irregular like the described scar.

Correct Answer: B

Rationale: The correct answer is B: Shakiness and dizziness. Hypoglycemia is characterized by low blood sugar levels, leading to symptoms such as shakiness and dizziness. This is because the brain requires glucose for energy, and when levels drop too low, these symptoms can occur. Increased thirst and urination (A) are more indicative of hyperglycemia, where blood sugar levels are too high. Blurred vision and headaches (C) can be symptoms of both hyperglycemia and hypoglycemia but are less specific to hypoglycemia. Fatigue and weight loss (D) are not typical symptoms of hypoglycemia.