One hour after a left thoracotomy, a patient reports incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 50 mLs of bloody drainage, and the nurse observes fluctuation in the water seal chamber. Which action should the nurse take?

Administer pain medication as prescribed.

Notify the healthcare provider immediately.

Reposition the patient to the unaffected side.

Document the findings and continue to monitor the drain.

Answer and Explanation

The Correct Answer is A

A. Administering pain medication is the priority action in this scenario. The patient is experiencing significant post-surgical pain, which can impair their ability to breathe deeply and effectively. Addressing pain will improve comfort and facilitate better respiratory effort.

B. Notifying the healthcare provider immediately is not warranted based on the current findings. The amount of drainage (50 mL) is within expected limits for the first hour after surgery, and fluctuation in the water seal chamber indicates the chest tube is functioning properly.

C. Repositioning the patient to the unaffected side may help with comfort but is not the most appropriate action to address the pain or improve respiratory status in this situation.

D. Documenting the findings and continuing to monitor the drain is important but does not address the patient’s immediate need for pain relief.

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Correct Answer is C

Explanation

A. Compartment syndrome is a complication of fractures, particularly when swelling within a closed muscle compartment compromises circulation. However, it typically presents with severe localized pain, paresthesia, pallor, and pulselessness, not systemic symptoms like shortness of breath and chest pain.

B. Hypovolemic shock can occur due to significant blood loss from fractures, but it is characterized by hypotension, tachycardia, and altered mental status rather than chest pain and shortness of breath.

C. Fat embolism syndrome (FES) is a serious complication of long bone fractures. Fat globules from the bone marrow can enter the bloodstream and lodge in the lungs, causing respiratory distress, chest pain, hypoxemia, and sometimes a petechial rash. The timing (24 hours post-injury) and symptoms suggest FES.

D. Venous thromboembolism (VTE) can cause similar symptoms, but it typically develops later than 24 hours post-injury and is less common immediately after fractures compared to FES.

A. Assess the patient's vital signs B. Check the patient's blood pressure C. Assess the patient's lung sounds D. Obtain a complete medical history

Correct Answer is C

Explanation

A. Assessing the patient’s vital signs is important but is not the first priority during an acute asthma attack. The primary concern is airway patency and breathing effectiveness.

B. Checking the patient’s blood pressure is part of a comprehensive assessment but is not the immediate priority in this scenario. It does not directly address the respiratory distress associated with an asthma attack.

C. Assessing the patient’s lung sounds is the first priority as it provides critical information about the severity of the airway obstruction and the effectiveness of the patient’s breathing. Identifying wheezing, diminished breath sounds, or silent chest (absence of airflow) is essential for immediate intervention.

D. Obtaining a complete medical history is important for long-term management but is not the priority during an acute asthma attack. Immediate assessment and stabilization take precedence.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has multiple long bone fractures caused by a motor-vehicle crash that happened 24 hr ago. The client tells the nurse he is short of breath and experiencing chest pain. The nurse should assess the client further for which of the following potential complications?

Correct Answer is C

Explanation

A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment should the nurse complete first?

Correct Answer is C

Explanation

A nurse is caring for a child who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take?

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

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

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.)

Postural drainage with percussion and vibration is ordered twice daily for a patient with chronic obstructive pulmonary disease (COPD). Which intervention should the nurse include in the plan of care?

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD) and a prescription for oxygen therapy at 4L/min via nasal cannula. Which of the following actions should the nurse take?

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 auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds?