A client sustains a puncture wound of the chest wall as the result of an industrial accident. The nurse knows that a chest tube will be inserted to reestablish
positive pressure in the pleural cavity.
atmospheric pressure in the thoracic space.
intrapulmonic pressure in the thoracic cavity.
negative pressure in the pleural space.
The Correct Answer is D
A. Positive pressure in the pleural cavity: The pleural space normally maintains negative pressure relative to atmospheric pressure. Positive pressure would collapse the lung rather than reestablish normal expansion. Inserting a chest tube is intended to restore the physiological negative pressure, not create positive pressure.
B. Atmospheric pressure in the thoracic space: Atmospheric pressure is outside the body, and exposure of the pleural space to it (as occurs in an open pneumothorax) can collapse the lung. The goal of a chest tube is to remove air or fluid and restore negative intrapleural pressure, not maintain atmospheric pressure in the pleural cavity.
C. Intrapulmonic pressure in the thoracic cavity: Intrapulmonic pressure refers to the pressure within the alveoli, which fluctuates during inspiration and expiration. A chest tube does not directly restore intrapulmonic pressure; it acts to reestablish normal pleural pressures, which allows the lungs to expand properly.
D. Negative pressure in the pleural space: The pleural space normally maintains negative pressure relative to the atmosphere, which keeps the lungs expanded. A puncture wound disrupts this negative pressure, causing lung collapse. Inserting a chest tube removes air or fluid and restores the negative pressure, allowing the lung to re-expand and reestablish normal respiratory mechanics.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Blood pressure 130/72, pulse 90, respirations 32: These values show mild changes from baseline and could reflect pain, anxiety, or mild physiological response. They are not immediately indicative of increased intracranial pressure.
B. Blood pressure 110/70, pulse 120, respirations 30: This pattern shows hypotension with compensatory tachycardia and mild tachypnea. While concerning, it may reflect hypovolemia rather than acute neurological deterioration.
C. Blood pressure 156/60, pulse 58, respirations 12: This represents Cushing’s triad—hypertension with widened pulse pressure, bradycardia, and irregular or slowed respirations—which is a classic sign of increased intracranial pressure and impending brain herniation. This is a neurological emergency requiring immediate intervention.
D. Blood pressure 148/78, pulse 112, respirations 28: These are elevated but less concerning than the pattern seen in option C. This may indicate pain, stress, or mild ICP increase but is not immediately life-threatening.
Correct Answer is A
Explanation
A. 1170 mL: Using the Parkland formula (4 mL × body weight in kg × % TBSA burned), the total fluid for the first 24 hours is calculated: 4 × 78 × 60 = 18,720 mL. Half of this (9,360 mL) is administered in the first 8 hours. To determine the hourly rate: 9,360 ÷ 8 = 1,170 mL/hour. This is the correct rate for the initial 8-hour resuscitation period.
B. 585 mL: This is half of the correct hourly rate. Administering only 585 mL/hour would under-resuscitate the client, risking hypoperfusion and shock.
C. 4680 mL: This number may represent half of the total 24-hour fluid requirement, but it is not the per-hour rate. Administering all 4,680 mL at once would be unsafe and could cause fluid overload.
D. 9360 mL: This is the total volume for the first 8 hours, not the hourly rate. Delivering the entire 9,360 mL at once would be extremely dangerous and could result in cardiovascular compromise and pulmonary edema.
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