A nurse in the emergency department is caring for a patient who was injured in a motor-vehicle crash. The patient reports dyspnea and severe pain.
The nurse notes that the patient’s chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following?
Flail chest
Hemothorax
Atelectasis
Pneumothorax
The Correct Answer is A
Choice A rationale
The symptoms described, including the paradoxical movement of the chest wall (moving inward during inspiration and outward during expiration), are indicative of a flail chest, which is a life-threatening condition that occurs when a segment of the rib cage breaks due to trauma and becomes detached from the rest of the chest wall.
Choice B rationale
Hemothorax is a collection of blood in the space between the chest wall and the lung (the pleural cavity). It’s often caused by chest trauma. It does not cause the chest to move inward during inspiration and outward during expiration.
Choice C rationale
Atelectasis is a complete or partial collapse of the entire lung or area (lobe) of the lung. It does not cause the chest to move inward during inspiration and outward during expiration.
Choice D rationale
Pneumothorax is a collapsed lung. It does not cause the chest to move inward during inspiration and outward during expiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
MRSA, or Methicillin-resistant Staphylococcus aureus, is a type of bacteria that is resistant to many antibiotics. Antiviral medications are used to treat viral infections, not bacterial infections like MRSA1234.
Choice B rationale
Patients with MRSA are typically placed on contact precautions, not airborne precautions. This is because MRSA is primarily spread through direct contact with an infected wound or from contaminated hands, not through the air.
Choice C rationale
While MRSA can survive on hands, it typically survives for less than an hour. However, the exact duration can vary depending on the conditions.
Choice D rationale
Bathing patients with water and chlorhexidine gluconate is a common practice to help control MRSA. Chlorhexidine gluconate is an antiseptic that kills a wide range of bacteria, including MRSA1234.
Correct Answer is A
Explanation
Choice A rationale
Before administering digoxin, it is crucial to measure the patient’s apical pulse. Digoxin affects the heart rate, and a low pulse could indicate that the dose needs to be adjusted.
Choice B rationale
Offering a light snack is not specifically required before administering digoxin.
Choice C rationale
While it’s always important to monitor a patient’s blood pressure, it’s not specifically required before administering digoxin.
Choice D rationale
Weighing the patient is not specifically required before administering digoxin.
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