Nokea
The nurse is caring for a client with tension pneumothorax. Which nursing assessment would alert the nurse to the development of a mediastinal shift in this client?
- A. Fluctuation of the fluid in the water-seal chamber
- B. Shift of rib cage toward affected side
- C. Sucking sound heard on inspiration and expiration
- D. Shift of trachea, esophagus, heart, and great vessels
Correct Answer: D
Rationale: In a tension pneumothorax, the air is sucked into the pleural cavity and cannot escape. The air accumulates and pushes the trachea, esophagus, heart, and great vessels toward the unaffected side. Fluctuation of the fluid in the water-seal chamber is an expected finding. There may be a paradoxical movement of the ribs but not a shifting to the side. A sucking sound may be heard with a pneumothorax, but air moves in and cannot escape out.
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A client is admitted to the emergency department with a stab wound and is now presenting dyspnea, tachypnea, and sucking noise heard on inspiration and expiration. The nurse should care for the wound in which manner?
- A. Clean the wound and leave open to the air
- B. Apply vented dressing
- C. Apply airtight dressing
- D. Apply direct pressure to the wound
Correct Answer: C
Rationale: The client has developed a pneumothorax, and the best action is to prevent further deflation of the affected lung by placing an airtight dressing over the wound. A vented dressing would be used in a tension pneumothorax, but because air is heard moving in and out, a tension pneumothorax is not indicated. Applying direct pressure is required if active bleeding is noted.
What are the condition(s) that make up Virchow's triad? Select all that apply.
- A. Hypercoagulability
- B. Disruption of the vessel lining
- C. Hypocoagulability
- D. Edema
- E. Venostasis
Correct Answer: A,B,E
Rationale: Three conditions, referred to as Virchow's triad, predispose a person to clot formation: venostasis, disruption of the vessel lining, and hypercoagulability. Edema plays no part in Virchow's triad.
Which entry by the nurse into the medical record is appropriate for a client who presents with symptoms indicative of acute bronchitis?
- A. Physical activity seems to increase incidence of paroxysmal coughing
- B. Frequent cough with sputum production noted
- C. Dry, irritating, nonproductive cough noted
- D. Fewer crackles today. No cough or mucus noted
Correct Answer: C
Rationale: Clinical manifestations indicative of acute bronchitis include fever, chills, malaise, headache, and a dry, irritating, nonproductive cough; therefore, the entry made into the client's medical record that is indicative of this respiratory disorder is as follows: Dry, irritating, nonproductive cough noted. 'Physical activity seems to increase incidence of paroxysmal coughing' is a judgment and not an observation. A frequent cough with sputum production is not anticipated for a client who is suspected of experiencing acute bronchitis; additionally, there is no description of the client's sputum, which is required when documenting objective client data. Documenting fewer crackles today does not provide enough detail and is not measurable.
The nurse identifies which finding to be most consistent prior to the onset of acute respiratory failure?
- A. Normal lung function
- B. Loss of lung function
- C. Chronic lung disease
- D. Slow onset of symptoms
Correct Answer: A
Rationale: Acute respiratory failure occurs suddenly in clients who previously had normal lung function.
What is the reason for chest tubes after thoracic surgery?
- A. Draining secretions, air, and blood from the thoracic cavity
- B. Allowing air into the pleural space
- C. Indicating when the lungs have re-expanded by ceasing to bubble
- D. Draining secretions and blood while allowing air to remain in the thoracic cavity
Correct Answer: A
Rationale: After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. Allowing air into the pleural space, indicating when lungs have re-expanded, and draining secretions and blood while air remains in the thoracic cavity are not the reasons for chest tubes after thoracic surgery.