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

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Health Assessment Practice Questions Questions

Question 1 of 9

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 9

What should be the first step in managing a client with suspected spinal cord injury?

Correct Answer: A

Rationale: The correct first step is to immobilize the spine (A) in a suspected spinal cord injury to prevent further damage. This helps to stabilize the spine and prevent any potential movement that could worsen the injury. Providing pain relief (B) should come after immobilization. Assessing for signs of spinal shock (C) is important but comes after immobilization. Placing the client in a supine position (D) can be part of immobilization but is not the first step.

Question 3 of 9

Which food should be avoided by clients prone to heartburn from GERD?

Correct Answer: C

Rationale: The correct answer is C: Chocolate. Chocolate is known to trigger heartburn in individuals with GERD due to its high fat content and caffeine. Fat relaxes the lower esophageal sphincter, allowing stomach acid to flow back up the esophagus, leading to heartburn. Caffeine can also relax the sphincter and trigger acid reflux. Lettuce (A) and eggs (B) are generally well-tolerated and do not commonly trigger heartburn. Butterscotch (D) may be high in fat and sugar, but it is less likely to cause heartburn compared to chocolate.

Question 4 of 9

What is the first priority for a client experiencing an acute asthma attack?

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. During an acute asthma attack, the priority is to open the airways quickly to improve breathing. Bronchodilators work rapidly to dilate the constricted airways, providing immediate relief. Corticosteroids are used for long-term management and take time to be effective. Administering morphine is not recommended as it can depress the respiratory system. Performing an ECG is not necessary in the acute management of an asthma attack.

Question 5 of 9

A nurse is interviewing a 75-year-old patient. Why might the interview take longer with this patient?

Correct Answer: A

Rationale: The correct answer is A. Older adults may have a longer story to tell due to their wealth of life experiences. This can include medical history, family background, and personal stories that may impact their health. It is important for the nurse to gather all relevant information to provide appropriate care. Choice B is incorrect because not all older adults are lonely, and the reason for a longer interview is not solely based on the need for social interaction. Choice C is incorrect because while some older adults may experience cognitive decline, it is not a blanket statement that all older adults lose mental abilities. Choice D is incorrect because hearing loss is not a universal issue among older adults, and assuming so can lead to ageist stereotypes.

Question 6 of 9

A patient's vision is recorded as 20/80 in each eye. The nurse recognizes that this finding indicates:

Correct Answer: A

Rationale: The correct answer is A: poor vision. In the 20/80 visual acuity notation, 20 represents the test distance in feet, and 80 represents the line on the eye chart that the patient can read. Therefore, a person with 20/80 vision can only see at 20 feet what a person with normal vision can see at 80 feet. This indicates poor vision as the patient's visual acuity is significantly below normal. Summary: - Choice B (acute vision) is incorrect as 20/80 vision indicates poor vision, not exceptional sharpness. - Choice C (normal vision) is incorrect as 20/80 vision is below normal range. - Choice D (presbyopia) is incorrect as presbyopia is a condition related to aging and difficulty focusing on close objects, not specifically indicated by 20/80 vision.

Question 7 of 9

Which of the following is most likely to increase the risk of sexually transmitted diseases (STDs)?

Correct Answer: D

Rationale: The correct answer is D because all choices (A, B, and C) can increase the risk of STDs. Alcohol use can impair judgment leading to risky sexual behavior. Certain sexual practices (such as unprotected sex or having multiple partners) can directly increase the risk of STD transmission. Oral contraception does not protect against STDs, so individuals relying solely on it may still be at risk. Therefore, all of the above factors can contribute to an increased risk of contracting STDs.

Question 8 of 9

During the examination of a patient in her third trimester of pregnancy, the nurse notices that the patient's thyroid gland is slightly enlarged. No enlargement had been noted previously. The nurse suspects that:

Correct Answer: C

Rationale: Step-by-step rationale for why choice C is correct: 1. Enlargement of the thyroid gland during pregnancy is a normal finding due to hormonal changes. 2. The thyroid gland enlarges to meet the increased demands of thyroid hormone production. 3. This condition is known as gestational thyrotoxicosis and is usually benign. 4. No further testing is needed for thyroid cancer unless other concerning symptoms are present. Summary: A: Not relevant as iodine deficiency is not typically associated with thyroid enlargement in pregnancy. B: Incorrect as early signs of goitre would involve more pronounced symptoms than just slight enlargement. D: Unnecessary as thyroid cancer is not a common concern in this scenario of a slightly enlarged thyroid in the third trimester of pregnancy.

Question 9 of 9

A 45-year-old man arrives at the clinic and tells the nurse that he has been experiencing severe chest pain. Upon assessment, the nurse notes that his pain radiates to his left arm. The nurse's priority action would be:

Correct Answer: B

Rationale: The correct answer is B: Assess vital signs and oxygen saturation levels. This is the priority action because the patient's symptoms suggest a possible cardiac event. Assessing vital signs and oxygen saturation levels can provide crucial information on the patient's condition and help determine the urgency of the situation. Administering pain medication (choice A) should not be done before assessing the patient's vital signs. Having the patient walk around (choice C) could worsen the situation if it is indeed a cardiac event. Ordering an EKG (choice D) is important but should come after assessing vital signs to guide further evaluation and treatment.

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