Nokea
The nurse is preparing a client for emergency thoracic surgery. What would the nurse document in the assessment?
- A. Emergency contacts
- B. IV fluids ordered
- C. General statement of the client's condition
- D. Detailed physical assessment
Correct Answer: C
Rationale: If the surgery is an emergency, physical assessment may be limited to a general statement of the client's condition, a list of emergency measures and treatments done, and vital signs. The nurse would not document emergency contacts or a detailed physical assessment. The nurse would document the IV fluids running and not any that are ordered.
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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.
The nurse knows the mortality rate is high in lung cancer clients due to which factor?
- A. Increase in women smokers
- B. Increased incidence among the elderly
- C. Increased exposure to industrial pollutants
- D. Few early symptoms
Correct Answer: D
Rationale: Because lung cancer produces few early symptoms, its mortality rate is high. Lung cancer has increased in incidence due to an increase in the number of women smokers, a growing aging population, and exposure to pollutants but these are not directly related to the incidence of mortality rates.
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.
The nurse is caring for a 2-year-old child who experienced near-drowning. The nurse will monitor for what possible complication?
- A. Atelectasis
- B. Acute respiratory distress syndrome
- C. Metabolic alkalosis
- D. Respiratory acidosis
Correct Answer: B
Rationale: Factors associated with the development of acute respiratory distress syndrome include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. The nurse would not monitor for atelectasis, metabolic alkalosis, or respiratory acidosis in this scenario.
The client diagnosed with acute respiratory distress syndrome (ARDS) presents with severe hypoxemia, despite oxygen administration via face mask. The nurse anticipates and prepares for which prescription from the health care provider (HCP)?
- A. Intermittent positive pressure breathing (IPPB)
- B. Increasing oxygen to 12 to 15 L flow
- C. Insertion of endotracheal (ET) tube
- D. Insertion of chest tube
Correct Answer: C
Rationale: To maintain the client's airway, an ET tube or tracheostomy tube will be inserted for administration of mechanical ventilation. Mechanical ventilation uses positive end-expiratory pressure (PEEP), not IPPB. The use of IPPB is appropriate for respiratory failure, not ARDS. Because the client is not experiencing a pneumothorax based on the clinical manifestations, a chest tube is not indicated for reinflation. Increasing the oxygen flow rate via mask does not maintain patency of the airway; however, the use of mechanical ventilation is supported for this purpose.