Nokea
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.
You may also like to solve these questions
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which of the following information best supports this diagnosis?
- A. Weak, nonproductive cough effort
- B. Large amounts of greenish sputum
- C. Respiratory rate of 28 breaths/minute
- D. Resting pulse oximetry (SPO2) of 85%
Correct Answer: A
Rationale: The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.
The nurse is caring for a patient who has just been admitted with pneumococcal pneumonia has a temperature of 38.7 C (101.7 F) with a frequent cough and symptoms of severe pleuritic chest pain. Which of the following prescribed medications should the nurse give first?
- A. Guaifenesin
- B. Acetaminophen
- C. Azithromycin
- D. Codeine phosphate
Correct Answer: C
Rationale: Early initiation of antibiotic therapy has been demonstrated to reduce mortality. The other medications also are appropriate and should be given as soon as possible, but the priority is to start antibiotic therapy.
The nurse is caring for a patient who has just had a thoracentesis. Which of the following information is most important to communicate to the health care provider?
- A. BP is 150/90 mm Hg.
- B. Oxygen saturation is 89%.
- C. Pain level is 5/10 with a deep breath.
- D. Respiratory rate is 24 when lying flat.
Correct Answer: B
Rationale: Oxygen saturation would be expected to improve after a thoracentesis. A saturation of 89% indicates that a complication such as pneumothorax may be occurring. The other assessment data also indicate a need for ongoing assessment or intervention, but the low oxygen saturation is the priority.
Which of the following information obtained by the nurse about a patient who has human immunodeficiency virus (HIV) and active tuberculosis (TB) disease is most important to communicate to the health care provider?
- A. The Mantoux test had an induration of only 8 mm.
- B. The chest x-ray showed infiltrates in the upper lobes.
- C. The patient is being treated with antiretrovirals for HIV infection.
- D. The patient has a cough that is productive of blood-tinged mucus.
Correct Answer: C
Rationale: Drug interactions can occur between the antiretrovirals used to treat HIV infection and the medications used to treat tuberculosis. The other data are expected in a patient with HIV and TB disease.
The nurse is caring for a patient who has a steering wheel injury as a result of an automobile accident. Which of the following findings should be of most concern to the nurse during the initial assessment?
- A. Paradoxical chest movement
- B. The complaint of chest wall pain
- C. A heart rate of 110 beats/minute
- D. A large bruised area on the chest
Correct Answer: A
Rationale: Paradoxical chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.