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The nurse is caring for a patient in the emergency department who has an open stab wound to the right chest. Which of the following actions should the nurse implement first?
- A. Position the patient so that the right chest is dependent.
- B. Keep the head of the patient's bed at no more than 30 degrees elevation.
- C. Tape a nonporous dressing on three sides over the chest wound.
- D. Cover the sucking chest wound firmly with an occlusive dressing.
Correct Answer: C
Rationale: The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the right side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30-45 degrees to facilitate breathing.
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The nurse is developing a teaching plan for a patient with a 12 pack-year history of cigarette smoking. Which of the following information should the nurse include in the plan of care?
- A. Computed tomography (CT) screening for lung cancer
- B. Options for smoking cessation
- C. Reasons for annual sputum cytology testing
- D. Erlotinib therapy to prevent tumour risk
Correct Answer: B
Rationale: Because smoking is the major cause of lung cancer, the most important role for the nurse is educating patients about the benefits of and means of smoking cessation. Early screening of at-risk patients using sputum cytology, chest x-ray, or CT scanning has not been effective in reducing mortality. Erlotinib may be used in patients who have lung cancer but not to reduce risk for developing tumours.
The nurse notes new onset confusion in an older-adult patient in a long-term care facility. The patient is normally alert and oriented. In which order should the nurse take the following actions?
- A. Obtain the oxygen saturation.
- B. Check the patient's pulse rate.
- C. Document the change in status.
- D. Notify the health care provider.
Correct Answer: A,B,D,C
Rationale: Assessment for physiological causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessed first, then circulation. After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done.
The nurse is caring for a patient who had a thoracotomy 1 hour ago and reports incisional pain at a level 7 out of 10 and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which of the following actions is best for the nurse to take next?
- A. Administer the prescribed PRN morphine.
- B. Assist the patient to deep breathe and cough.
- C. Milk the chest tube gently to remove any clots.
- D. Tape the area around the insertion site of the chest tube.
Correct Answer: A
Rationale: The patient is unlikely to take deep breaths or cough until the pain level is lower. A chest tube output of 100 mL is not unusual in the first hour after thoracotomy and would not require milking of the chest tube. An air leak is expected in the initial postoperative period after thoracotomy.
The nurse is caring for a patient who has a right-sided chest tube following a thoracotomy and has continuous bubbling in the suction-control chamber of the collection device. Which of the following actions should the nurse implement?
- A. Document the presence of a large air leak.
- B. Obtain and attach a new collection device.
- C. Notify the surgeon of a possible pneumothorax.
- D. Take no further action with the collection device.
Correct Answer: D
Rationale: Continuous bubbling is expected in the suction-control chamber and indicates that the suction-control chamber is connected to suction. An air leak would be detected in the water-seal chamber. There is no evidence of pneumothorax. A new collection device is needed when the collection chamber is filled.
Which of the following nursing actions is most effective in preventing aspiration pneumonia in patients who are at risk?
- A. Turn and reposition immobile patients at least every 2 hours.
- B. Place patients with altered consciousness in side-lying positions.
- C. Monitor for respiratory symptoms in patients who are immuno-suppressed.
- D. Provide for continuous subglottic aspiration in patients receiving enteral feedings.
Correct Answer: B
Rationale: The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position. Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration in patients at risk. Monitoring of parameters such as breath sounds and oxygen saturation will help detect pneumonia in immunocompromised patients, but it will not decrease the risk for aspiration. Continuous subglottic suction is recommended for intubated patients but not for all patients receiving enteral feedings.