The nurse is caring for a 34-year-old woman who developed Stevens-Johnson syndrome while undergoing treatment with carbamazepine (Tegretol). The patient is being transferred from the intensive care unit to the medical unit.
The nurse knows the best choice of roommates for this patient is which of the following?

Choice A rationale

While obtaining a complete history is important for diagnosis, it is not the immediate priority. The patient's altered mental status, chest pain, and chills suggest a serious infectious or cardiopulmonary process like pneumonia, which can rapidly progress. Delaying the assessment of vital signs and oxygen saturation to gather a detailed history could be detrimental, as the patient's condition may worsen during that time.

Choice B rationale

Providing a pneumococcal vaccine is a prophylactic measure for pneumonia prevention. While potentially relevant for a patient at risk for or diagnosed with pneumonia, it is not an immediate life-saving intervention. The priority is to assess and stabilize the patient's current condition, not to prevent a future illness. Vaccination is a secondary intervention once the patient is stabilized.

Choice C rationale

The nursing priority in this situation is to obtain baseline vital signs and oxygen saturation. The patient's symptoms of altered mental status, chest pain, and chills are red flags for a serious cardiopulmonary condition like pneumonia. Assessing vital signs, including oxygen saturation, provides crucial data to determine the severity of the illness and guide immediate interventions to stabilize the patient's condition. Normal oxygen saturation is 95-100%.

Choice D rationale

Obtaining a sputum culture is a diagnostic procedure used to identify the causative organism of a respiratory infection. While an important step for guiding targeted antibiotic therapy, it is not the nursing priority. Sputum collection can be time-consuming, and the results are not immediately available. The priority is to assess the patient's current physiological status and provide supportive care, such as oxygen, if needed, based on the vital signs

Paradoxical chest movement is the hallmark sign of flail chest. This occurs when two or more adjacent ribs are fractured in two or more places, creating a free-floating segment of the chest wall. During inspiration, the negative intrathoracic pressure causes the unstable segment to be pulled inward, while the rest of the chest expands. During expiration, the segment bulges outward, opposite the normal movement of the chest wall.

Choice B rationale

Flail chest involves significant trauma to the chest wall, including multiple rib fractures. This causes severe pleuritic pain, which is exacerbated by the movement of the chest wall during inspiration. The fractured ribs and associated soft tissue injury irritate the parietal pleura, leading to a sharp, stabbing pain that the patient describes as being worse with deep breaths.

Choice C rationale

Bradycardia is not a typical finding in flail chest. The patient's pain, respiratory distress, and potential hypoxemia trigger a sympathetic nervous system response. This compensatory mechanism leads to an increase in heart rate to maintain cardiac output and oxygen delivery to the tissues. Therefore, tachycardia is a more expected finding in a patient with flail chest. Normal heart rate is 60 to 100 beats per minute.

Choice D rationale

Jaundice, characterized by yellowing of the skin and eyes, is a result of hyperbilirubinemia, a condition associated with liver dysfunction, biliary obstruction, or excessive red blood cell destruction. It is not a direct finding or complication of flail chest, which is a musculoskeletal and respiratory injury. Jaundice would be a coincidental finding and not a direct sign.

Choice E rationale

Chest pain is a prominent and expected finding in a patient with flail chest. The pain is a direct result of the trauma, including multiple rib fractures and the associated soft tissue and muscle injury. The severity of the pain is often directly related to the number and location of the fractures and is a major contributor to the patient's respiratory distress. .