The nurse is assessing the respiratory status of a client who has suffered a fractured rib. Which observation, if made by the nurse, would not be directly related to the fractured rib?
Pleural effusion on the unaffected side
Shallow breathing due to pain
Guarding behavior when taking deep breaths
Localized chest pain on inspiration
The Correct Answer is A
A. Pleural effusion on the unaffected side is not directly related to a fractured rib. While rib fractures can lead to complications such as pneumothorax or hemothorax, pleural effusion on the opposite side is likely caused by another condition, such as infection or malignancy, and should be investigated separately.
B. Shallow breathing due to pain is a common response to a fractured rib, as the client may avoid deep breaths to minimize discomfort.
C. Guarding behavior when taking deep breaths is directly related to the pain caused by the fractured rib and is an expected observation.
D. Localized chest pain on inspiration is a hallmark symptom of a fractured rib, as the injury causes discomfort with chest wall movement during breathing.
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Related Questions
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.
Correct Answer is A
Explanation
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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