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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Decreased PaO2 <60mmHg: A hallmark of fat embolism syndrome (FES) is hypoxemia, which results in a PaO2 less than 60 mmHg. This is a key indicator of the severity of respiratory compromise in FES and ARDS.
B. PaO2 greater than 80mmHg: This would not be consistent with FES. Fat embolism often causes significant hypoxemia, and PaO2 greater than 80 mmHg would indicate adequate oxygenation.
C. Decreased platelet count and hematocrit levels: In fat embolism syndrome, there is often a decrease in platelet count and hematocrit due to disseminated intravascular coagulation (DIC), which can occur as a complication of fat embolism.
D. Changes in ST segment and T-wave: Electrocardiographic changes, including changes in ST segment and T-wave, are commonly seen in fat embolism syndrome due to myocardial injury, hypoxemia, or shock.
E. PaCO2 40mmHg: A PaCO2 of 40 mmHg is within normal limits and does not indicate any significant respiratory distress or abnormality that would be expected in fat embolism syndrome.
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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