Practice Question
A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?
Answer Choices:
Correct Answer:
Administer oxygen via nasal cannula.
Rationale:
🟦 A sucking chest wound is an open pneumothorax that can rapidly impair ventilation and oxygenation, evidenced by RR 40/min and tachycardia.
🟦 Immediate oxygen supports improved oxygen delivery while other emergency interventions are initiated.
🟦 Early supplemental oxygen is a key stabilization step because hypoxia can worsen shock and tissue perfusion quickly.
🟦 This client shows signs of respiratory compromise and possible evolving shock (weak pulse, HR 118), so supporting oxygenation is urgent.
🟦 While definitive management includes an occlusive dressing and chest tube setup, oxygen is an immediate measure to reduce hypoxemia during rapid response actions.
Raise the foot of the bed to a 90° angle.
🟦 This is not an appropriate positioning strategy and can worsen respiratory mechanics by compromising diaphragmatic movement.
🟦The client’s priority issue is breathing, not aggressive foot elevation.
Prepare to insert a central line.
🟦A central line is not the first step in managing an open pneumothorax with acute respiratory distress.
🟦Immediate priorities are airway and breathing support, then definitive chest management.
Remove the dressing to inspect the wound.
🟦Removing a dressing can allow more air entry and worsen the pneumothorax.
🟦The priority is maintaining coverage and supporting breathing rather than exposing the wound unnecessarily.
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This question is from Custom NUR213 Final Assessment FA II 2025 Assessment 1 which contains 63 questions.
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From Exam
Custom NUR213 Final Assessment FA II 2025 Assessment 1
63 Questions
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- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN Custom Exam(s)
- Answer Choices: 4