A patient is brought to the emergency department with a penetrating wound to the neck. The patient is dyspneic and cyanotic, and has evidence of subcutaneous emphysema. Which intervention does the nurse prioritize?
1. Intubation
2. Notification of next of kin
3. X-ray of the cervical spine
4. Administration of an IV beta blocker
1
Rationale 1: Penetrating trauma to the neck is associated with a high degree of morbidity and mortality. Airway involvement includes dyspnea, cyanosis, subcutaneous emphysema, hoarseness, and air bubbling from the wound. The key is early identification of the need for intubation before the patient has no airway at all.
Rationale 2: The patient is critically injured and next of kin should be notified, but this is not the priority intervention.
Rationale 3: An X-ray evaluation of the cervical spine is important but does not hold the highest priority.
Rationale 4: Medication administration is not the highest priority for this patient.
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