A nurse in the emergency department is assessing a patient who was in a motor vehicle crash.
Findings include absent breath sounds in the left lower lobe with dyspnea, BP 118/68 mmHg, heart rate 124 bpm, respirations 38 breaths/min, temperature 38.6 °C, and oxygen saturation 90%. Which of the following actions should the nurse do first?

Initiate IV access.

Obtain a chest X-ray.

Administer oxygen via high-flow mask.

Prepare for chest tube insertion.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While IV access is important for fluid resuscitation and medication administration, establishing an airway and ensuring adequate oxygenation are the most immediate priorities. The patient's oxygen saturation is critically low at 90%, indicating severe hypoxemia. Following the ABCs of resuscitation (Airway, Breathing, Circulation), addressing the breathing problem takes precedence over initiating an IV line.

Choice B rationale

A chest X-ray is a diagnostic tool that provides crucial information about the underlying pathology, such as a pneumothorax. However, obtaining a chest X-ray takes time and should not delay immediate, life-saving interventions. The patient's respiratory distress and low oxygen saturation require immediate action to support oxygenation, as delayed intervention can lead to respiratory failure and cardiac arrest.

Choice C rationale

The patient's respiratory rate of 38 breaths/min and oxygen saturation of 90% indicate severe respiratory distress and hypoxemia. Administering high-flow oxygen directly addresses the life-threatening lack of oxygen, improving tissue oxygenation and supporting cellular function. This is the most critical first step in managing a patient with compromised breathing, following the ABCs of resuscitation.

Choice D rationale

Preparing for a chest tube insertion is a vital intervention for a suspected pneumothorax, which is suggested by the absent breath sounds. However, this is a procedural step that follows the initial stabilization of the patient's breathing. The immediate priority is to provide oxygen to prevent further desaturation, while simultaneously preparing for definitive treatment. The preparation should happen concurrently with oxygen administration, not before it.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

Fragrances in cosmetics and personal care products are common causes of allergic contact dermatitis. These are often complex mixtures of chemical allergens that can trigger a T-cell mediated immune response, leading to a delayed-type hypersensitivity reaction. Avoiding products containing these known irritants is a key preventative strategy to reduce the frequency and severity of future episodes.

Choice B rationale

Washing the skin with very hot water is detrimental to the skin's barrier function. Hot water strips the skin of its natural oils (sebum), leading to excessive dryness and micro-fissures. This compromised skin barrier makes the skin more permeable to allergens and irritants, exacerbating existing dermatitis and increasing susceptibility to future episodes. The skin should be cleansed with lukewarm water.

Choice C rationale

Wearing gloves constantly, especially those made of latex or vinyl, can create a moist environment that traps sweat and irritants, leading to maceration and irritation of the skin. This can worsen existing dermatitis and potentially cause a new form of contact dermatitis. Gloves should only be worn for specific tasks and for limited periods to prevent this moisture-induced skin damage.

Choice D rationale

Fabric softeners often contain chemicals and fragrances that are known contact allergens and irritants. These substances can remain in the clothing fibers after washing and come into direct contact with the skin, triggering a hypersensitivity reaction. Therefore, the nurse should advise against using fabric softeners to reduce exposure to potential allergens and prevent future episodes of contact dermatitis.

A. 50 ml of drainage in the drainage collection chamber. B. Drainage system maintained below the patient's chest. C. Occlusive dressing in place over the chest tube insertion site. D. Excessive bubbling in the water seal chamber.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

This is an expected finding. Following a thoracotomy, a certain amount of drainage is anticipated from the chest tube as a result of inflammation and bleeding from the surgical site. A drainage volume of 50 mL is considered normal in the immediate postoperative period and should be monitored closely. However, if the drainage exceeds 100 mL/hour, it could indicate hemorrhage and requires immediate notification of the healthcare provider.

Choice B rationale

This is a correct principle of chest tube management. The drainage system must be kept below the level of the patient's chest to prevent fluid from flowing back into the pleural cavity. The principle of gravity ensures that air and fluid from the pleural space continue to drain into the collection chamber, which is essential for re-expanding the lung and maintaining negative intrapleural pressure.

Choice C rationale

This is an essential component of chest tube care. An occlusive dressing is applied over the chest tube insertion site to prevent air from entering the pleural space from the outside. This dressing ensures that the closed drainage system remains airtight and prevents a pneumothorax, which could cause the lung to collapse again. The dressing must be kept intact and taped on all sides.

Choice D rationale

Excessive bubbling in the water seal chamber is an unexpected finding. The water seal chamber should normally have gentle tidaling (fluctuations) with respirations, indicating changes in intrapleural pressure. Constant, vigorous bubbling suggests a significant air leak, which could be from the insertion site, tubing, or within the chest, indicating a persistent pneumothorax or a problem with the system. It needs to be investigated.

Choice E rationale

Vigorous bubbling in the suction control chamber is an incorrect finding. The suction control chamber should have gentle, continuous bubbling to indicate that the appropriate level of suction is being applied. Vigorous or turbulent bubbling is inefficient, causes the water to evaporate quickly, and does not increase the amount of suction applied to the chest. It simply indicates excessive airflow

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Naxlex Comprehensive Predictor Exams

The nurse caring for a patient with repeated episodes of contact dermatitis is providing instruction to prevent future episodes. Which information should the nurse include?

Correct Answer is A

Explanation

The nurse is assessing the functioning of a chest tube drainage system in a patient with a chest injury who has just returned from the recovery room following a thoracotomy with wedge resection. What are the expected assessment findings?

Correct Answer is ["A","B","C"]

Explanation

A nurse is assessing a patient following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax?

The nurse is caring for a patient admitted to the hospital with alterations in oxygenation. The nurse understands that which of the following are common clinical manifestations in patients with alterations in oxygenation? Select all that apply.

The patient has an order for clindamycin 600 mg IV every 12 hours. Clindamycin from the pharmacy comes as 600 mg in 50 ml. It is to run over 20 minutes. The nurse should set the pump to deliver how many ml/hr?

A patient with a chest tube accidentally pulls the tube out while turning in bed. What should the nurse do first?

A 22-year-old patient has an itchy rash on his left arm that has been diagnosed as contact dermatitis. Which of the following patient statements indicates a need for more education?

A 55-year-old patient with leukemia is being seen in the clinic for complaints of burning pain in the back. The patient has been diagnosed with shingles. The nurse would expect which medication classification to be ordered to reduce pain and halt the progression of the disease?

A patient in the emergency department has dyspnea, asymmetrical chest expansion, and an oxygen saturation of 90%. A chest X-ray shows a collapsed lung and blood accumulation in the pleural space. What is the correct diagnosis?