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A nurse is caring for a client who has a pneumothorax.

 

Exhibits



A nurse is reviewing the client's medical record. Which of the following prescriptions should the nurse anticipate for a client who has a pneumothorax?



For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

A.

Obtain ABGS.

B.

Prepare for insertion of a chest tube.

C.

Obtain intravenous access.

D.

Computed tomography (CT) of the chest

E.

Pulmonary Function Tests (PFTS)

F.

Thoracentesis

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"B"}}

Anticipated:

Obtain ABGs: This is anticipated because arterial blood gases help evaluate oxygenation and acid-base status. Since the client has a low O₂ saturation (85%) and is showing signs of respiratory distress, ABGs are essential for guiding oxygen therapy and further interventions.

Prepare for insertion of a chest tube: A chest tube is the primary treatment for a pneumothorax. It allows air to escape the pleural space and re-expand the lung. The client's absent breath sounds and labored breathing indicate a significant air accumulation that needs urgent management.

Obtain intravenous access: IV access is essential to administer fluids, analgesics, or emergency medications, especially in a hypotensive client (BP 92/64 mm Hg) showing signs of shock and respiratory compromise.

Computed tomography (CT) of the chest: A CT scan may be ordered to assess the extent of lung injury or to evaluate for concurrent thoracic trauma. It provides more detailed imaging than a chest x-ray and is appropriate once the client is stabilized.

Non-essential:

Thoracentesis: Thoracentesis is used to remove fluid from the pleural space, such as in pleural effusion, not air, as in pneumothorax. Performing thoracentesis in this case could worsen the condition or lead to further complications.

Contraindicated:

Pulmonary Function Tests (PFTs): PFTs are not appropriate in this scenario. They require the client to perform forced breathing maneuvers, which are unsafe and impractical for someone in acute respiratory distress with a pneumothorax.

 


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Related Questions

Correct Answer is D

Explanation

A. Traveling to an underdeveloped country is more commonly associated with risk for hepatitis A and E due to contaminated food or water, not hepatitis C.
B. Eating raw shellfish is a risk factor for hepatitis A, not hepatitis C.
C. Working in a child care center may increase risk for hepatitis A through fecal-oral transmission, but not hepatitis C.
D. Hepatitis C is primarily transmitted through blood-to-blood contact, and having multiple tattoos, especially if done with non-sterile equipment, increases the risk for hepatitis C infection.

Correct Answer is C

Explanation

A. Pain medication is important but secondary to stabilizing the client’s circulation.
B. Cleaning and dressing the wound is essential but should follow fluid resuscitation in major burns.
C. Administering IV fluids is the priority to prevent hypovolemic shock due to fluid loss from burn injuries.
D. A tetanus booster is important but not the immediate priority in emergency care.

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