The nurse is assessing a client who sustained a blunt chest injury. Which would indicate to the nurse that the client is exhibiting a flail chest?

Inward displacement of a rib section during inspiration

Continuous outward bulging of a rib section throughout breathing

Shift of mediastinal structures to affected side during inspiration

Deep, inspiratory stridor during inspiration

Answer and Explanation

The Correct Answer is A

A. Inward displacement of a rib section during inspiration is correct because flail chest occurs when two or more adjacent ribs are fractured in two or more places, creating a free-floating segment of the chest wall. This segment moves paradoxically, meaning it moves inward during inspiration and outward during expiration, which is the hallmark sign of flail chest. This paradoxical motion impairs ventilation and can lead to respiratory compromise.

B. Continuous outward bulging of a rib section throughout breathing is incorrect because flail chest is defined by paradoxical motion, not constant outward movement. Continuous outward bulging may suggest other chest wall deformities or localized swelling but is not diagnostic of flail chest.

C. Shift of mediastinal structures to affected side during inspiration is incorrect because mediastinal shift occurs in tension pneumothorax, not flail chest. In tension pneumothorax, air accumulates in the pleural space, pushing the heart and mediastinum toward the unaffected side, compromising circulation.

D. Deep, inspiratory stridor during inspiration is incorrect because stridor is an upper airway obstruction sign, not a characteristic of flail chest. Flail chest primarily affects ventilation mechanics and causes paradoxical chest wall movement rather than airway noise.

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Correct Answer is A

Explanation

A. Norepinephrine is a potent vasoconstrictor, and if it infiltrates peripheral tissue, it can cause severe tissue necrosis and extravasation injury. Administering it through a central venous catheteris the highest priority safety measurewhen initiating the infusion to prevent serious complications.

B. Continuous cardiac monitoring is importantbecause norepinephrine can cause tachycardia, arrhythmias, and increased myocardial oxygen demand, but the risk of tissue injury from peripheral administration is more immediately critical.

C. Assessing baseline blood glucose is not a priorityfor norepinephrine administration. Blood glucose monitoring may be relevant in critical care, but it does not directly prevent complications from norepinephrine infusion.

D. Documenting the client’s level of consciousness is important for ongoing assessment of perfusion and neurological status, but it is not the highest-priority actionat the time of initiating a vasopressor infusion.

A. Bandage around the posterior tube is loose. B. 2 cm of water is in the second chest tube chamber. C. The water in the water seal chamber rises and falls with inhalation/exhalation. D. Bubbling present in the water seal chamber when the client coughs.

Correct Answer is A

Explanation

A. A loose bandage around the chest tubecompromises the sterile sealof the dressing, which increases the risk of air entering the pleural spaceand infection. For a client following a pneumonectomy, maintaining a tight, sterile dressingis essential to prevent pneumothorax or subcutaneous emphysema. This finding requires immediate nursing intervention by reinforcing or replacing the dressingand monitoring the site for signs of air leakage or infection.

B. 2 cm of water in the suction control chamberis expected if suction is applied, depending on the prescribed water level. This is normal and indicates proper suction regulation.

C. Fluctuation (tidaling) in the water seal chamberwith inhalation and exhalation is expected. It indicates patent drainage and lung re-expansion. Lack of tidaling could indicate tube obstruction, kinking, or lung re-expansion.

D. Intermittent bubbling in the water seal chamber during coughingis normal. It occurs because increased intrathoracic pressuretemporarily forces air through the chest tube. Continuous bubbling at rest, however, would indicate an air leakand require intervention.

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The nurse is assessing a client who sustained a blunt chest injury. Which would indicate to the nurse that the client is exhibiting a flail chest?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse is assessing a client with a chest tube following a pneumonectomy. Which assessment finding requires nursing intervention?

Correct Answer is A

Explanation

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