Nokea
The nurse is assessing an adult patient following a motor vehicle accident. The nurse observes that the patient has an increased use of accessory muscles and is complaining of chest pain and shortness of breath. The nurse should recognize the possibility of what condition?
- A. Pneumothorax
- B. Anxiety
- C. Acute bronchitis
- D. Aspiration
Correct Answer: A
Rationale: If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The patient is anxious, has dyspnea and air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia. These symptoms are not definitive of pneumothorax, but because of the patients recent trauma they are inconsistent with anxiety, bronchitis, or aspiration.
You may also like to solve these questions
An x-ray of a trauma patient reveals rib fractures and the patient is diagnosed with a small flail chest injury. Which intervention should the nurse include in the patients plan of care?
- A. Suction the patients airway secretions
- B. Immobilize the ribs with an abdominal binder
- C. Prepare the patient for surgery
- D. Immediately sedate and intubate the patient
Correct Answer: A
Rationale: As with rib fracture, treatment of flail chest is usually supportive. Management includes clearing secretions from the lungs, and controlling pain. If only a small segment of the chest is involved, it is important to clear the airway through positioning, coughing, deep breathing, and suctioning. Intubation is required for severe flail chest injuries, and surgery is required only in rare circumstances to stabilize the flail segment.
The nurse is caring for a 46-year-old patient recently diagnosed with the early stages of lung cancer. The nurse is aware that the preferred method of treating patients with nonsmall cell tumors is what?
- A. Chemotherapy
- B. Radiation
- C. Surgical resection
- D. Bronchoscopic opening of the airway
Correct Answer: C
Rationale: Surgical resection is the preferred method of treating patients with localized nonsmall cell tumors with no evidence of metastatic spread and adequate cardiopulmonary function. The other listed treatment options may be considered, but surgery is preferred.
While planning a patients care, the nurse identifies nursing actions to minimize the patients pleuritic pain. Which intervention should the nurse include in the plan of care?
- A. Avoid actions that will cause the patient to breathe deeply
- B. Ambulate the patient at least three times daily
- C. Arrange for a soft-textured diet and increased fluid intake
- D. Encourage the patient to speak as little as possible
Correct Answer: A
Rationale: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. A soft diet is not necessarily indicated and there is no need for the patient to avoid speaking. Ambulation has multiple benefits, but pain management is not among them.
The perioperative nurse is writing a care plan for a patient who has returned from surgery 2 hours prior. Which measure should the nurse implement to most decrease the patients risk of developing pulmonary emboli (PE)?
- A. Early ambulation
- B. Increased dietary intake of protein
- C. Maintaining the patient in a supine position
- D. Administering aspirin with warfarin
Correct Answer: A
Rationale: For patients at risk for PE, the most effective approach for prevention is to prevent deep vein thrombosis. Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression stockings are general preventive measures. The patient does not require increased dietary intake of protein directly related to prevention of PE, although it will assist in wound healing during the postoperative period. The patient should not be maintained in one position, but frequently repositioned, unless contraindicated by the surgical procedure. Aspirin should never be administered with warfarin because it will increase the patients risk for bleeding.
The nurse is caring for a patient at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis?
- A. Incentive spirometry
- B. Intermittent positive-pressure breathing (IPPB)
- C. Positive end-expiratory pressure (PEEP)
- D. Bronchoscopy
Correct Answer: A
Rationale: Strategies to prevent atelectasis, which include frequent turning, early ambulation, lung-volume expansion maneuvers (deep breathing exercises, incentive spirometry), and coughing, serve as the first-line measures to minimize or treat atelectasis by improving ventilation. In patients who do not respond to first-line measures or who cannot perform deep-breathing exercises, other treatments such as positive end-expiratory pressure (PEEP), continuous or intermittent positive-pressure breathing (IPPB), or bronchoscopy may be used.