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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. Notifying the client's family may be appropriate after assessing the client and identifying the cause of the confusion. However, it is not the first action, as the priority is to determine if the confusion is due to a medical condition requiring immediate attention.

B. Instructing the client to return to their room addresses the wandering behavior but does not address the underlying cause of the new onset confusion. Without further assessment, this action may delay necessary interventions.

C. Asking the UAP to push fluids assumes that dehydration is the cause of the confusion without evidence. While encouraging hydration may be beneficial later, it is essential first to assess for other potential causes, such as infection or hypoxia.

D. Assessing the client's lung fields and temperature is the first priority because new onset confusion in an older adult is often a symptom of an underlying medical issue, such as infection (e.g., pneumonia or urinary tract infection) or hypoxia. Early assessment helps identify the cause and guide appropriate interventions.

A. Obtain an arterial blood gas and order a portable chest x-ray. B. Instruct the UAP to keep the client on strict bed rest. C. Assess the client for dyspnea and altered mental status. D. Contact the healthcare provider for a ventilation and perfusion scan.

Correct Answer is C

Explanation

A. Obtaining an arterial blood gas and ordering a chest x-ray may be necessary to evaluate the client further, but the nurse must first assess the client to determine the presence of clinical signs of fat embolism syndrome (FES), such as respiratory distress or neurological changes.

B. Keeping the client on strict bed rest may help reduce the risk of further complications, but it is not the first priority. Immediate assessment of the client’s condition is necessary to identify signs of fat embolism syndrome.

C. Assessing the client for dyspnea and altered mental status is the first priority because these symptoms are early indicators of fat embolism syndrome. Early recognition and intervention are critical in preventing further complications.

D. Contacting the healthcare provider for a ventilation and perfusion scan may be appropriate after assessing the client, but it is not the first action. Immediate assessment is essential to determine the urgency of the situation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 70-year-old client in a nursing home is found wandering in the hall and has a new onset confusion. Which action should the registered nurse implement ́ first?

Correct Answer is D

Explanation

Unlicensed assistive personnel (UAP) reports a client diagnosed with a fractured femur has "fatty globules" floating in the urinal. Which intervention should the nurse implement first?

Correct Answer is C

Explanation

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 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?

A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for immediate notification?

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?

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

Which assessment data would warrant immediate intervention by the nurse?

A patient with asthma presents with daily peak flow rates consistently at 45% of their personal best. What is the most appropriate action the nurse should take?