A nurse is caring for a client who has a flail chest. Which of the following actions should the nurse take?

Provide humidified oxygen.

Administer antibiotic medication.

Implement fluid restriction

Administer acetaminophen orally.

Answer and Explanation

The Correct Answer is A

A. Clients with flail chest often experience compromised respiratory function due to the paradoxical movement of the chest wall. Providing humidified oxygen can help improve oxygenation and maintain airway patency, especially if the client is experiencing hypoxia.

B. Administering antibiotic medication is not a primary intervention for a flail chest unless there is evidence of an associated infection, such as pneumonia
C. Fluid restriction is not typically indicated for a client with a flail chest unless there are specific indications, such as heart failure or renal dysfunction.

D. While managing pain is important, flail chest often requires more aggressive pain management strategies, such as opioid analgesics or regional anesthesia, especially if the pain is severe and affects respiratory effort. Acetaminophen alone may not be sufficient for effective pain control in this situation.

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Correct Answer is C

Explanation

A. Bladder spasms are a common postoperative complication after TURP, and they are typically associated with the irritation of the bladder wall. Cold compresses may be helpful for reducing muscle spasms or swelling in other situations, but they are not typically effective for relieving bladder spasms specifically.
B. Securing the urinary catheter is important to prevent dislodgement and ensure proper drainage. However, securing it to the upper left quadrant of the abdomen is not a standard practice.
C. The appropriate response is often to irrigate the catheter to relieve the obstruction and restore normal flow. While 0.9% sodium chloride (normal saline) is typically used for irrigation, the term "intermittent" refers to manually irrigating the catheter at intervals to flush out any blockages, which is an appropriate approach when there is a concern about obstruction.
D. Encouraging the client to urinate every 2 hours is not feasible or necessary in this situation.

A. Use moisturizing lotion while massaging the client's bony prominences. B. Instruct the client to sit on a rubber ring when seated in a chair. C. Place pillows between the client's knees when in a side-lying position. D. Raise the head of the client's bed to a 90° angle.

Correct Answer is C

Explanation

C. Placing pillows between the client's knees when in a side-lying position helps maintain proper alignment of the hips and prevents the affected leg from crossing over the midline, which could lead to muscle
contractures or discomfort. It also helps prevent pressure on bony prominences and reduces the risk of skin breakdown.
A. Keeping the bony prominences too moist could lead to increased risk of skin breakdown.
B. This is not recommended as it could exacerbate muscle weakness or discomfort on the affected side and may not provide adequate support for proper alignment.
D. Raising the head of the bed to a 90° angle is not typically indicated for clients with hemiplegia. It may increase the risk of aspiration

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A nurse is caring for a client who has a flail chest. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include?

Correct Answer is C

Explanation

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