A nurse is caring for a client who has a pneumothorax.
ExhibitsA 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.
Nursing Test Bank
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1971"]
Explanation
Face: 4.5%
Left arm: 9%
Total TBSA = 4.5 + 9 = 13.5%
Fluid needed in 24 hours = 4 mL × 73 kg × 13.5 = 3942 mL (rounded)
Half of this is given in the first 8 hours: 3942 ÷ 2 = 1971 mL
Correct Answer is B
Explanation
A. Active bleeding is important but airway and breathing take precedence.
B. Altered respirations indicate airway compromise or respiratory distress, which is the most critical priority to assess and manage first.
C. Facial asymmetry is a sign of injury but less urgent than airway or breathing problems.
D. Soft-tissue edema can impair breathing but is secondary to immediate respiratory assessment.
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