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A patient is admitted to the respiratory unit with flail chest. The nurse understands that a flail chest is:

A condition in which the ribs are fractured in multiple places, resulting in a segment of the chest wall that moves independently during respiration

A condition in which the chest wall is paralyzed, resulting in difficulty breathing

A condition in which the lungs are unable to fully expand, resulting in decreased oxygenation

A condition in which the diaphragm becomes weak, resulting in decreased lung expansion

Answer and Explanation

The Correct Answer is A

A. Flail chest occurs when multiple ribs are fractured in more than one location, creating a free-floating segment of the chest wall. This segment moves paradoxically during respiration, meaning it moves inward during inspiration and outward during expiration, which impairs effective breathing and oxygenation.

B. Paralysis of the chest wall may occur in conditions like spinal cord injuries but is not the defining characteristic of flail chest.

C. While decreased oxygenation can occur with flail chest due to impaired ventilation, the defining feature is the paradoxical movement of the fractured rib segment.

D. Weakness of the diaphragm can impair lung expansion, but this is characteristic of conditions like diaphragmatic paralysis, not flail chest.

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Correct Answer is C

Explanation

A. While ensuring that a client with an inguinal hernia voids before discharge is important, it does not warrant immediate intervention unless there are signs of urinary retention or other complications.

B. Refusing to deep breathe after an open cholecystectomy can increase the risk of postoperative complications like atelectasis, but it does not require immediate intervention unless there are signs of respiratory distress or infection.

C. Pain on inspiration in a client with deep vein thrombosis (DVT) is a potential sign of pulmonary embolism (PE), a life-threatening complication. Immediate assessment and intervention are critical to prevent further deterioration.

D. Refusing to turn for three hours increases the risk of pressure injuries, but this is not as urgent as the potential for a pulmonary embolism. The nurse should address this issue promptly but not before assessing the client with possible PE.

A. Anxiety attack B. Pneumonia C. Pulmonary embolism D. Asthma exacerbation

Correct Answer is C

Explanation

A. While anxiety can cause rapid breathing and confusion, the patient's clinical presentation (dyspnea, confusion, tachycardia, hypotension, and oxygen desaturation) is more consistent with a serious physical condition, such as a pulmonary embolism, rather than an anxiety attack.

B. Pneumonia could cause dyspnea and confusion, but the rapid onset of symptoms, along with the patient's history of prolonged bed rest and risk factors, suggests a pulmonary embolism rather than pneumonia.

C. Pulmonary embolism (PE) is a life-threatening condition that can occur in patients on prolonged bedrest, especially after a pelvic fracture. The patient’s symptoms of dyspnea, confusion, tachycardia, hypotension, and oxygen desaturation are classic signs of PE. This requires immediate intervention, including anticoagulation and possibly thrombolytic therapy.

D. Asthma exacerbation typically presents with wheezing and difficulty breathing, but it would not typically cause the severe hypotension, confusion, and rapid oxygen desaturation seen in this patient.

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A patient is admitted to the respiratory unit with flail chest. The nurse understands that a flail chest is:

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Naxlex Comprehensive Predictor Exams

Which assessment data would warrant immediate intervention by the nurse?

Correct Answer is C

Explanation

A patient on prolonged bedrest following a pelvic fracture becomes dyspneic and confused. Pulse = 135 beats/minute, blood pressure = 90/50 mmHg, respirations = 36/minute, Oxygen saturation starts dropping rapidly. Which of the following conditions should the nurse prepare to treat for this patient?

Correct Answer is C

Explanation

A nurse is applying oxygen via nasal cannula to a client diagnosed with chronic obstructive pulmonary disease (COPD). The client reports extreme shortness of breath. At what rate should the nurse set the flowmeter?

During assessment of a client on the respiratory unit, the pulse oximetry monitor indicates a drop of SpO2 from 98% to 87% over four hours in a client who previously had normal range oxygen saturation level. Which of the following actions should the nurse perform first?

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

A nurse is caring for a client who is receiving heparin 3,800 units subcutaneous daily. Available is heparin 5,000 units/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth.)

A nurse is providing teaching to a client about manifestations of pulmonary embolism (PE). Which of the following findings should the nurse include in the teaching? (Select All that Apply.)

A patient with chronic obstructive pulmonary disease (COPD) presents with dyspnea and wheezing. What is the most appropriate initial nursing intervention to manage these symptoms?

A client is admitted to the emergency room with an asthma attack. To decrease the client's dyspnea and anxiety, which of the following interventions will the nurse perform?

A nurse is providing discharge teaching to a client who has a Plaster of Paris walking cast on his left lower leg. Which of the following instructions should the nurse include?