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. Give a prescribed analgesic for temperature above 101° F (38.3°C), orally. B. Place an indwelling urinary catheter and attach a bedside drainage unit. C. Send the client to x-ray for a flat plate of the abdomen. D. Insert a nasogastric tube (NGT) and attach to low intermittent suction (LIS).

Correct Answer is D

Explanation

A. Give a prescribed analgesic for temperature above 101° F (38.3°C), orally: Oral medications are generally contraindicated in clients with suspected bowel obstruction or severe vomiting, as they can worsen symptoms or be poorly absorbed. Managing fever is secondary to resolving the underlying cause of the gastrointestinal distress.

B. Place an indwelling urinary catheter and attach a bedside drainage unit: While monitoring urine output is important in assessing fluid balance and renal perfusion, it is not the immediate priority in managing suspected gastrointestinal obstruction with ongoing emesis and severe abdominal pain.

C. Send the client to x-ray for a flat plate of the abdomen: Imaging is essential for diagnosing bowel obstruction, but this should not delay urgent decompression measures. The client’s symptoms foul-smelling emesis, post-surgical status, hyperactive bowel sounds, and pain suggest a possible bowel obstruction that requires prompt intervention.

D. Insert a nasogastric tube (NGT) and attach to low intermittent suction (LIS): Dark brown, foul-smelling emesis is indicative of a bowel obstruction with possible feculent vomiting. Immediate NGT insertion relieves gastric pressure by decompression, prevents further vomiting, reduces aspiration risk, and helps stabilize the patient before diagnostic imaging or further treatment.

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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

Correct Answer is D

Explanation

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