A nurse cares for a patient who had a chest tube placed six hours ago and refuses to take deep breaths because of the pain. What action should the nurse take?
Encourage the patient to take shallow breaths to help with the pain.
Auscultate the patient's anterior and posterior lung field
Ambulate the patient in the hallway to promote deep breathin
Administer pain medication and encourage the patient to take deep breaths.
The Correct Answer is D
Choice A rationale
Encouraging shallow breaths is contraindicated as it can lead to atelectasis and subsequent pneumonia. Deep breathing and coughing are vital post-chest tube insertion to re-expand the lung and clear secretions. Shallow breathing diminishes the ventilatory effort, increasing the risk for retained secretions and alveolar collapse, which can impair gas exchange and oxygenation, exacerbating the patient's condition and potentially prolonging recovery.
Choice B rationale
While auscultating lung fields is a standard assessment, it does not directly address the patient's pain-related refusal to perform deep breathing. The immediate priority is to manage the pain that is inhibiting a crucial therapeutic activity, which is deep breathing. Assessing lung sounds without first addressing the pain does not solve the root problem that is preventing the patient from participating in their care, thus delaying essential lung expansion and recovery.
Choice C rationale
Ambulation is a beneficial intervention for promoting lung expansion and preventing complications, however, it should not be the first action. Without adequate pain control, the patient will be unable to ambulate effectively or take deep breaths during the activity. Administering pain medication first makes ambulation more tolerable and effective by addressing the primary barrier to the patient's participation in therapeutic activities, ensuring the intervention is successful.
Choice D rationale
Pain is the primary reason the patient is refusing to take deep breaths. Administering pain medication addresses the underlying cause of the patient's reluctance. Once the pain is managed, the nurse can effectively encourage the patient to perform deep breathing exercises, which are essential for re-expanding the collapsed lung, clearing secretions, and preventing complications such as atelectasis and pneumonia, thereby facilitating a more rapid and successful recovery
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Choice A rationale
A patient with a new spinal cord injury on a rotating bed is not at a high risk for developing a pulmonary embolism. The rotating bed is specifically designed to prevent complications associated with immobility, such as venous stasis and pressure ulcers. The constant movement of the bed helps to maintain blood flow and prevent the pooling of blood in the extremities, thereby reducing the risk of deep vein thrombosis and subsequent pulmonary embolism.
Choice B rationale
A young obese patient with a fractured femur is at a high risk for developing a pulmonary embolism. Obesity is a hypercoagulable state, increasing the baseline risk of thrombus formation. A fractured femur, especially if it requires immobilization, causes significant venous stasis and potential endothelial injury. This combination of factors, adhering to Virchow's triad, creates a highly prothrombotic environment, making the development of DVT and PE very likely.
Choice C rationale
A patient who had a reaction to contrast dye yesterday is not at a high risk for developing a pulmonary embolism. Allergic reactions to contrast dye are typically associated with hypersensitivity responses, affecting systems such as the respiratory, cardiovascular, and integumentary. There is no known physiological mechanism or evidence to suggest that a contrast dye reaction, even a severe one, directly increases the risk of developing a pulmonary embolism in the subsequent days.
Choice D rationale
An older patient who is one day post hip replacement surgery is at a very high risk for developing a pulmonary embolism. Surgical procedures, particularly orthopedic surgeries like hip replacements, cause significant endothelial injury and a hypercoagulable state. The post-operative period often involves extended immobility, leading to venous stasis. These three components of Virchow's triad converge to create an ideal environment for the formation of a deep vein thrombosis, which can easily embolize to the lungs.
Choice E rationale
A young man with an exacerbation of asthma is not at a high risk for developing a pulmonary embolism. Asthma is a chronic inflammatory disease of the airways characterized by bronchoconstriction. While a severe asthma exacerbation can lead to hypoxemia and respiratory distress, it does not directly cause the hypercoagulable state, venous stasis, or endothelial injury necessary to form a deep vein thrombosis. Therefore, it is not a direct risk factor for a pulmonary embolism
Correct Answer is ["A","B","E"]
Explanation
Paradoxical chest movement is the hallmark sign of flail chest. This occurs when two or more adjacent ribs are fractured in two or more places, creating a free-floating segment of the chest wall. During inspiration, the negative intrathoracic pressure causes the unstable segment to be pulled inward, while the rest of the chest expands. During expiration, the segment bulges outward, opposite the normal movement of the chest wall.
Choice B rationale
Flail chest involves significant trauma to the chest wall, including multiple rib fractures. This causes severe pleuritic pain, which is exacerbated by the movement of the chest wall during inspiration. The fractured ribs and associated soft tissue injury irritate the parietal pleura, leading to a sharp, stabbing pain that the patient describes as being worse with deep breaths.
Choice C rationale
Bradycardia is not a typical finding in flail chest. The patient's pain, respiratory distress, and potential hypoxemia trigger a sympathetic nervous system response. This compensatory mechanism leads to an increase in heart rate to maintain cardiac output and oxygen delivery to the tissues. Therefore, tachycardia is a more expected finding in a patient with flail chest. Normal heart rate is 60 to 100 beats per minute.
Choice D rationale
Jaundice, characterized by yellowing of the skin and eyes, is a result of hyperbilirubinemia, a condition associated with liver dysfunction, biliary obstruction, or excessive red blood cell destruction. It is not a direct finding or complication of flail chest, which is a musculoskeletal and respiratory injury. Jaundice would be a coincidental finding and not a direct sign.
Choice E rationale
Chest pain is a prominent and expected finding in a patient with flail chest. The pain is a direct result of the trauma, including multiple rib fractures and the associated soft tissue and muscle injury. The severity of the pain is often directly related to the number and location of the fractures and is a major contributor to the patient's respiratory distress. .
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