A patient is brought to the Emergency Department with a gunshot wound to the chest. The healthcare professional assesses an abnormality involving a pleural rupture that acts as a one-way valve, permitting air to enter on inspiration but preventing its escape by closing during expiraton. What action by the healthcare professional is the priority?

Assist with a chest tube insertion

Give the patient low-flow oxygen

Assess for clubbing of fingernails

Draw arterial gases

Answer and Explanation

The Correct Answer is A

A. Assist with a chest tube insertion: A gunshot wound to the chest with a one-way valve pleural rupture indicates a tension pneumothorax, a life-threatening condition. Air enters the pleural space with each breath but cannot escape, leading to increased intrathoracic pressure, lung collapse, and mediastinal shift, which can compromise venous return and cardiac output. Immediate chest tube insertion or needle decompression is necessary to relieve pressure and restore normal lung function.

B. Give the patient low-flow oxygen: Oxygen therapy may help improve oxygenation, but it does not address the underlying issue of trapped air causing intrathoracic pressure buildup. Without intervention to release the trapped air, respiratory distress and cardiovascular collapse can occur.

C. Assess for clubbing of fingernails: Clubbing is a sign of chronic hypoxia seen in long-term respiratory diseases but is not relevant in the acute management of a tension pneumothorax. The priority is to relieve the trapped air and restore normal lung expansion.

D. Draw arterial gases: While arterial blood gases can help assess oxygenation and ventilation status, they do not treat the underlying tension pneumothorax. Immediate decompression is required before diagnostic tests to prevent rapid deterioration and potential cardiac arrest.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Atherosclerotic lesion: An atherosclerotic lesion can lead to reduced blood flow to the myocardium, but it is not the direct trigger for angina pectoris. Rather, it is a contributing factor to the development of conditions that cause angina.

B. Myocardial necrosis: Myocardial necrosis refers to irreversible cell damage due to prolonged ischemia, such as in a myocardial infarction. This is not a trigger for angina pectoris but rather a consequence of severe and prolonged ischemia.

C. Myocardial ischemia: Myocardial ischemia is the primary trigger for angina pectoris. It occurs when there is an imbalance between the oxygen supply and demand in the heart muscle, typically due to narrowed coronary arteries. This insufficient blood flow results in chest pain or discomfort characteristic of angina.

D. Hyperlipidemia: Hyperlipidemia is a risk factor for atherosclerosis and subsequent coronary artery disease but does not directly trigger angina pectoris. It contributes to the underlying processes that lead to myocardial ischemia.

A. Pulse oximetry 98% B. Diminished breath sounds over painful chest area C. Respiratory rate 34 D. ABG pH level of 7.38 E. Asymmetrical chest movements, especially on inspiration

Correct Answer is ["B","C","E"]

Explanation

A. Pulse oximetry 98%: A pulse oximetry reading of 98% indicates adequate oxygen saturation, which does not strongly suggest a pneumothorax. Patients with a pneumothorax may have lower oxygen saturation levels, but this reading alone is not indicative of the condition.

B. Diminished breath sounds over painful chest area: Diminished breath sounds are a significant clinical manifestation of pneumothorax, as air in the pleural space prevents normal lung expansion and decreases airflow to the affected side.

C. Respiratory rate 34: An elevated respiratory rate (tachypnea) is often observed in patients with pneumothorax as they may struggle to breathe effectively. This clinical manifestation indicates respiratory distress and is consistent with the condition.

D. ABG pH level of 7.38: A pH level of 7.38 indicates acidosis, which may occur in cases of pneumothorax due to impaired gas exchange and respiratory distress. This abnormal finding on arterial blood gases supports the suspicion of pneumothorax.

E. Asymmetrical chest movements, especially on inspiration: Asymmetrical chest movements are a classic sign of pneumothorax, where the affected lung does not expand as fully as the unaffected lung during inspiration, leading to visible differences in chest wall movement.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the trigger for angina pectoris?

Correct Answer is C

Explanation

A patient arrives in the ED after an automobile accident. Which of the following clinical manifestations leads the nurse to suspect a pneumothorax? (Select all that apply) (Select All that Apply.)

Correct Answer is ["B","C","E"]

Explanation

What type of angina is characterized by vasospasms of coronary arteries and causes unpredictable chest pain?

A disproportionate thickening of the interventricular septum is the hallmark of which form of cardiomyopathy?

When talking about hypertension, we know that it can physiologically be caused by all of the following except

Primary hypertension:

Which long-term resident is most likely to be exhibiting the signs and symptoms of chronic obstructive pulmonary disease (COPD)?

A patient with severe pericarditis has developed a large pericardial effusion. The patient is symptomatic. The physician orders what type of procedure to help treat this condition?

A person wishes to reduce the risk of developing coronary artery disease. This person has normal lipid panel. What risk factor reduction would the healthcare professional advise for this person?