A nurse is planning care for a patient with a flail chest. Which of the following interventions are appropriate for this patient? Select all that apply. Directions for Drag and Drop: Click and drag the correct possible answers from the left box to the right to indicate your answer.
Administering high-flow oxygen therapy
Administering analgesics for pain relief
Encouraging deep breathing and coughing exercises
Prepare for the need for intubation
Encouraging the patient to lie flat on their back
Correct Answer : A,B,C,D
A. Administering high-flow oxygen therapy: Patients with flail chest often experience hypoxemia due to impaired ventilation and paradoxical chest wall movement. Providing high-flow oxygen helps maintain adequate oxygenation and tissue perfusion while reducing the risk of respiratory distress.
B. Administering analgesics for pain relief: Severe pain from rib fractures can inhibit deep breathing and effective coughing, increasing the risk of atelectasis and pneumonia. Adequate analgesia, including opioids or regional blocks, allows the patient to breathe more comfortably and participate in respiratory exercises safely.
C. Encouraging deep breathing and coughing exercises: Respiratory physiotherapy is critical to prevent pulmonary complications such as atelectasis and pneumonia. Even with chest wall instability, guided deep breathing and coughing help mobilize secretions and improve lung expansion while maintaining oxygenation.
D. Prepare for the need for intubation: Severe flail chest can lead to respiratory failure due to inadequate ventilation and hypoxemia. The nurse must anticipate and be prepared for intubation and mechanical ventilation if the patient’s respiratory status deteriorates, ensuring rapid response to acute respiratory compromise.
E. Encouraging the patient to lie flat on their back: Lying flat is contraindicated for flail chest patients because it can exacerbate paradoxical movement of the chest wall, increase respiratory effort, and worsen oxygenation. Elevating the head of the bed or maintaining a semi-Fowler’s position is preferred to facilitate ventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
A. Provide oral care every 12 hours: Oral care is an essential component of VAP prevention; however, every 12 hours is insufficient for mechanically ventilated patients. Evidence-based bundles recommend more frequent oral care, often every 2–4 hours, typically with chlorhexidine to reduce oropharyngeal colonization. This frequency does not meet best-practice standards.
B. Monitor ETT cuff pressure: Maintaining appropriate endotracheal tube cuff pressure (usually 20–30 cm H₂O) helps prevent microaspiration of contaminated oral and gastric secretions into the lower airway. Inadequate cuff pressure increases the risk of pathogen entry into the lungs, making regular monitoring a critical VAP prevention strategy.
C. Insert a nasogastric tube: Insertion of a nasogastric tube does not prevent VAP and may increase the risk of aspiration if not managed properly. Gastric distention and reflux can contribute to aspiration of gastric contents, thereby increasing pneumonia risk rather than reducing it.
D. Administer high doses of sedation: High sedation levels suppress cough reflexes, impair early mobilization, and prolong mechanical ventilation duration, all of which increase VAP risk. Current evidence supports daily sedation interruption and light sedation strategies rather than deep sedation.
E. Maintain head of the bed to at least 30 degrees: Elevating the head of the bed between 30–45 degrees reduces the risk of aspiration of gastric and oral secretions. This positioning decreases the likelihood of bacteria entering the lower respiratory tract and is a cornerstone of ventilator bundle protocols.
Correct Answer is D
Explanation
A. Prepare the patient for a transvenous pacemaker: Transvenous pacing is reserved for symptomatic bradycardia that is unresponsive to medications or when hemodynamic compromise occurs. Since this patient is alert, oriented, and hemodynamically stable, immediate pacing is not indicated.
B. Prepare the patient for cardioversion: Cardioversion is used for unstable tachyarrhythmias, not for bradycardia. Applying this intervention to a stable patient with sinus bradycardia would be inappropriate and potentially harmful.
C. Document that the patient is in normal sinus rhythm: Although sinus bradycardia may be normal for some patients (e.g., athletes), it is still important to notify the provider for further assessment and to determine if intervention or monitoring adjustments are needed. Documentation alone is insufficient.
D. Contact the provider: The patient’s heart rate is below normal, though currently stable. The nurse should notify the provider to report the bradycardia, allowing the provider to evaluate for possible causes, review medications, and determine if any interventions are necessary. This ensures safe, proactive management.
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