What is the priority action for a client with an open chest wound?

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Question 1 of 5

What is the priority action for a client with an open chest wound?

Correct Answer: A

Rationale: The correct answer is A: Apply a sterile dressing. Firstly, cover the wound with a sterile occlusive dressing to prevent air from entering the pleural space, reducing the risk of tension pneumothorax. This also helps to prevent infection and further complications. Administering morphine (B) or nitroglycerin (D) is not the priority in this situation as managing the chest wound is crucial. Applying an airtight dressing (C) may lead to tension pneumothorax if not done properly. Therefore, the immediate action should be to apply a sterile dressing to stabilize the wound and prevent further complications.

Question 2 of 5

What is the first priority for a client with suspected sepsis?

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. In sepsis, early fluid resuscitation is crucial to prevent hypotension and organ dysfunction. IV fluids help restore perfusion and stabilize the client. Administering antibiotics (choice B) is important but comes after fluid resuscitation. Performing a blood culture (choice C) is essential but not the first priority. Performing an abdominal assessment (choice D) is not directly related to managing sepsis and should not be the initial priority.

Question 3 of 5

The patient's record, laboratory studies, objective data, and subjective data together form the:

Correct Answer: A

Rationale: The correct answer is A: database. The patient's record, laboratory studies, objective data, and subjective data collectively form the database in healthcare. This term refers to a comprehensive collection of all pertinent information about a patient that is used for analysis, diagnosis, and treatment planning. The other choices are incorrect because B: admitting data specifically refers to information gathered at the time of admission, C: financial statement pertains to financial information, and D: discharge summary summarizes the patient's care and treatment at the time of discharge, not the entire patient record.

Question 4 of 5

Which of the following would be formulated by a nurse using diagnostic reasoning?

Correct Answer: C

Rationale: The correct answer is C: Diagnostic hypothesis. Nurses use diagnostic reasoning to formulate diagnostic hypotheses based on patient data and clinical judgment. They analyze symptoms and data to generate potential diagnoses. Choice A, nursing diagnosis, involves identifying patient problems related to nursing care. Choice B, medical diagnosis, is made by physicians to identify diseases or medical conditions. Choice D, diagnostic assessment, refers to the process of collecting and analyzing data to make a diagnosis. Diagnostic hypothesis aligns with the process of diagnostic reasoning in nursing practice.

Question 5 of 5

A patient is brought by ambulance to the emergency department with multiple injuries received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How should the nurse proceed with the data collection?

Correct Answer: B

Rationale: The correct answer is B. When a patient with severe injuries is brought to the emergency department, the nurse should prioritize performing a physical examination and initiating lifesaving measures while asking history questions simultaneously. This approach allows for immediate assessment and intervention to address any life-threatening conditions. Gathering history information while performing the examination ensures that critical details are not missed and helps in making timely decisions. Choosing option A could delay lifesaving interventions, while option C is not a priority during the initial assessment of a critically injured patient. Option D is incorrect as it prioritizes lifesaving measures over obtaining important history information during the initial assessment.

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