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A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take?
- A. Position the patient so that the left chest is dependent
- B. Tape a nonporous dressing on three sides over the chest wound
- C. Cover the sucking chest wound firmly with an occlusive dressing
- D. Keep the head of the patient's bed at no more than 30 degrees elevation
Correct Answer: B
Rationale: The correct initial action for a patient with an open stab wound to the chest is to tape a nonporous dressing on three sides over the chest wound. This dressing technique allows air to escape during expiration but prevents air from entering the pleural space during inspiration, helping to prevent tension pneumothorax. Placing the patient so that the left chest is dependent or covering the wound with an occlusive dressing can trap air in the pleural space, leading to tension pneumothorax. Keeping the head of the bed elevated at 30 to 45 degrees helps facilitate breathing and is not the first action to take when managing an open chest wound.
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After a bronchoscopy, what is the most appropriate intervention for a patient with a chronic cough?
- A. Elevate the head of the bed to 80 to 90 degrees.
- B. Keep the patient NPO until the gag reflex returns.
- C. Place the patient on bed rest for at least 4 hours after bronchoscopy.
- D. Notify the health care provider about blood-tinged mucus.
Correct Answer: B
Rationale: The correct intervention is to keep the patient NPO until the gag reflex returns after a bronchoscopy. This is important because a local anesthetic is used during the procedure to suppress the gag and cough reflexes. Monitoring the return of these reflexes helps prevent the risk of aspiration and ensures the patient can safely resume oral intake. While blood-tinged mucus can occur after bronchoscopy, it is a common occurrence and not a cause for immediate concern. Placing the patient on bed rest for an extended period is unnecessary, and elevating the head of the bed to a high-Fowler's position is not specifically required post-bronchoscopy.
The patient with idiopathic pulmonary arterial hypertension (IPAH) is receiving epoprostenol (Flolan). Which assessment information requires the most immediate action by the nurse?
- A. The oxygen saturation is 94%.
- B. The blood pressure is 98/56 mm Hg.
- C. The patient's central IV line is disconnected.
- D. The international normalized ratio (INR) is prolonged.
Correct Answer: C
Rationale: The most immediate action required by the nurse is to address the disconnected central IV line delivering epoprostenol (Flolan). Epoprostenol has a short half-life of 6 minutes, necessitating immediate reconnection to prevent rapid clinical deterioration. While oxygen saturation, blood pressure, and INR are important parameters requiring monitoring and intervention, the priority lies in ensuring the continuous delivery of the critical medication to stabilize the patient's condition.
A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and respirations of 42 breaths/minute. Which action should the nurse take first?
- A. Administer anticoagulant drug therapy.
- B. Notify the patient's healthcare provider.
- C. Prepare the patient for a spiral computed tomography (CT).
- D. Elevate the head of the bed to a semi-Fowler's position.
Correct Answer: D
Rationale: The patient presents with symptoms indicative of a pulmonary embolism (PE), such as chest pain, difficulty breathing, tachycardia, hypotension, and tachypnea. Elevating the head of the bed to a semi-Fowler's position is the priority to improve ventilation and gas exchange. This intervention should be initiated promptly to optimize oxygenation. Subsequent actions, such as notifying the healthcare provider, preparing for a spiral CT scan, and administering anticoagulant therapy, can follow after the patient's position is adjusted. The spiral CT scan is typically used to confirm the diagnosis of PE, and anticoagulant therapy is initiated upon confirmation of the diagnosis by the healthcare provider. Therefore, the immediate focus is on improving the patient's respiratory status by elevating the head of the bed.
The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?
- A. Oxygen saturation is 88%.
- B. Blood pressure is 145/90 mm Hg.
- C. Respiratory rate is 22 breaths/minute when lying flat.
- D. Pain level is 5 (on a 0 to 10 scale) with a deep breath.
Correct Answer: A
Rationale: The correct answer is 'Oxygen saturation is 88%.' Following a thoracentesis, oxygen saturation should improve. A saturation of 88% suggests a potential complication like pneumothorax. While the other assessment findings are important, the priority is to address the low oxygen saturation to prevent further complications. High blood pressure and respiratory rate may also need attention, but the immediate concern is the oxygen saturation level. Pain level, though significant for the patient's comfort, takes lower priority compared to the potential life-threatening issue of hypoxia.
A patient is scheduled for a computed tomography (CT) of the chest with contrast media. Which assessment finding should the nurse immediately report to the health care provider?
- A. Patient is claustrophobic.
- B. Patient is allergic to shellfish.
- C. Patient recently used a bronchodilator inhaler.
- D. Patient is not able to remove a wedding band.
Correct Answer: B
Rationale: The correct answer is that the patient is allergic to shellfish. This is crucial because the contrast media used in CT scans is iodine-based, and individuals with iodine allergies, such as those allergic to shellfish, are at risk of adverse reactions. It is important to identify and address this allergy to prevent potential complications. The other options do not directly impact the safety or effectiveness of the CT scan with contrast media. Claustrophobia can be managed with patient support, the recent use of a bronchodilator inhaler does not typically affect the CT procedure, and not being able to remove a wedding band is not a critical concern for the scan itself.