A client arrives to the emergency department (ED) following a motor vehicle collision. The nurse observes the client experiencing increasing dyspnea and notes absent breath sounds on the left side. Which procedure should the nurse prepare the client for?

Pulmonary function test.

Endotracheal intubation.

Chest tube insertion.

Bronchoscopy.

Answer and Explanation

The Correct Answer is C

A. Pulmonary function test: Pulmonary function tests assess chronic respiratory conditions such as asthma or COPD but are not appropriate during acute respiratory emergencies. In a trauma setting with absent breath sounds, these tests are irrelevant and would delay necessary life-saving interventions.

B. Endotracheal intubation: While intubation can support oxygenation in respiratory failure, it does not address the underlying issue if a pneumothorax or hemothorax is causing lung collapse. A chest tube is required first to re-expand the lung before or in conjunction with advanced airway support, if needed.

C. Chest tube insertion: Absent breath sounds on one side after trauma are strongly suggestive of a pneumothorax or hemothorax. A chest tube is urgently needed to evacuate air or blood from the pleural space and restore lung expansion, making this the most appropriate and immediate intervention.

D. Bronchoscopy: Bronchoscopy is used for visualizing the airway, retrieving foreign bodies, or assessing unexplained lung conditions. It is not a first-line emergency intervention for absent breath sounds following trauma and would not address the likely underlying cause such as a collapsed lung.

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Correct Answer is ["B","C","D","E"]

Explanation

A. Signs of respiratory tract infection: While clients with diabetes may have a higher risk for infections due to immune compromise, respiratory infections are not typically considered long-term complications of diabetes. This assessment is more relevant for acute care rather than chronic complication monitoring.

B. Sensation in feet and legs: Peripheral neuropathy is a common long-term complication of diabetes due to prolonged hyperglycemia damaging peripheral nerves. Assessing sensation helps detect early nerve damage and prevent complications such as foot ulcers and injuries.

C. Skin condition of lower extremities: Poor circulation and neuropathy can lead to delayed wound healing, dry skin, and increased risk of infections or ulcers. Examining the skin condition of the lower extremities helps identify early signs of peripheral vascular disease and diabetic foot complications.

D. Visual acuity: Diabetic retinopathy is a major chronic complication of type 2 DM, potentially leading to vision loss. Regular assessment of visual acuity is essential to detect changes early and refer the patient for ophthalmologic evaluation if needed.

E. Serum creatinine and blood urea nitrogen (BUN): Diabetic nephropathy can lead to progressive kidney damage. Monitoring kidney function through serum creatinine and BUN helps assess renal involvement and guide interventions to slow disease progression.

A. Encourage the client to use hard candy frequently to help relieve thirst. B. Provide the client with additional oral fluids of her preference. C. Measure the client's capillary glucose reading at regular intervals. D. Withhold the next diuretic dose until contacting the healthcare provider.

Correct Answer is A

Explanation

A. Encourage the client to use hard candy frequently to help relieve thirst: Clients with SIADH are usually on fluid restrictions to prevent further dilutional hyponatremia. Using non-liquid measures like hard candy, ice chips, or gum can help reduce the discomfort of persistent thirst without compromising fluid balance, making this a safe and supportive intervention.

B. Provide the client with additional oral fluids of her preference: Increasing fluid intake directly contradicts the management of SIADH, where excess antidiuretic hormone leads to water retention and hyponatremia. Additional fluids can exacerbate electrolyte imbalances and worsen neurological symptoms.

C. Measure the client's capillary glucose reading at regular intervals: While glucose monitoring may be necessary in clients with diabetes or altered mental status, thirst in SIADH is not related to hyperglycemia. This action would not address the underlying issue or contribute to symptom relief.

D. Withhold the next diuretic dose until contacting the healthcare provider: Diuretics may be used in SIADH to promote free water excretion. Withholding them without a specific clinical reason, such as hypotension or dehydration, may worsen fluid overload and hyponatremia.

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A client arrives to the emergency department (ED) following a motor vehicle collision. The nurse observes the client experiencing increasing dyspnea and notes absent breath sounds on the left side. Which procedure should the nurse prepare the client for?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. Which assessment(s) would the nurse complete to determine if a patient with type 2 diabetes mellitus (DM) is experiencing long term complications? Select all that apply

Correct Answer is ["B","C","D","E"]

Explanation

A client with chronic syndrome of inappropriate antidiuretic hormone (SIADH) reports to the nurse of being constantly thirsty. Which action should the nurse take?

Correct Answer is A

Explanation

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