The nurse is caring for a patient with multiple traumatic injuries following an occupational accident where the patient fell from a 30ft high ladder. Upon assessment, the-nurse hears bowel sounds in the chest. What should the nurse do next?

Determine when the patient last ate and call for spiritual advisor

Assess vital signs and immediately notify the trauma surgeon

Request an order for a chest x-ray and stop IV fluids

Medicate the patient's pain and obtain consent for surgery

Answer and Explanation

The Correct Answer is B

A) Determine when the patient last ate and call for spiritual advisor:
While it is important to gather a comprehensive history, including when the patient last ate, and to provide emotional support such as calling a spiritual advisor, these actions are not the priority in this situation. The immediate concern is the patient's physical condition and addressing the potential trauma to the chest and abdominal organs. Bowel sounds in the chest suggest a serious injury, such as a diaphragmatic rupture, which requires immediate surgical intervention.

B) Assess vital signs and immediately notify the trauma surgeon:
Hearing bowel sounds in the chest is a strong indication of a diaphragmatic injury, possibly a rupture, which can lead to the bowel being displaced into the chest cavity. This is a life-threatening emergency that can result in respiratory distress, impaired organ function, and infection. The nurse should assess vital signs to determine if the patient is stable or in shock and then immediately notify the trauma surgeon to facilitate urgent surgical intervention. Immediate surgical repair is necessary to prevent further complications such as respiratory compromise or sepsis.

C) Request an order for a chest x-ray and stop IV fluids:
A chest x-ray may be ordered later to confirm the presence of diaphragmatic injury or other chest trauma, but the priority action is to notify the trauma surgeon immediately. Stopping IV fluids is not appropriate in this situation; the patient likely needs continued fluid resuscitation, especially if they are in shock or have significant blood loss from their traumatic injuries.

D) Medicate the patient's pain and obtain consent for surgery:
Pain management is important for the patient’s comfort, but surgical intervention should not be delayed while obtaining consent. The trauma surgeon should be notified immediately, and surgery should be expedited without waiting for consent. In trauma cases, consent for life-saving procedures may be implied if the patient is unconscious or unable to provide consent due to the urgency of the situation.

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Correct Answer is ["D","E"]

Explanation

A) Pneumonia: Pneumonia is a direct cause of ARDS, as it involves direct inflammation and infection of the lung tissue, leading to impaired oxygen exchange and damage to the alveolar-capillary membrane. It results in fluid accumulation in the lungs, which is a key characteristic of ARDS.

B) Drowning: Drowning is another direct cause of ARDS. It involves the aspiration of water into the lungs, which directly damages lung tissue, causing pulmonary edema and impaired oxygenation.

C) Aspiration: Aspiration of food, liquid, or vomit into the lungs is also a direct cause of ARDS. The aspirated material can lead to chemical pneumonia, bacterial infection, and inflammation of the lungs, which in turn causes ARDS.

D) Sepsis: Sepsis is an indirect cause of ARDS. It can lead to widespread inflammation throughout the body, including the lungs, through the release of inflammatory mediators (cytokines, interleukins, etc.). These systemic inflammatory responses can increase capillary permeability in the lungs, causing fluid to leak into the alveoli, which leads to ARDS.

E) Blood Transfusion: Blood transfusion, particularly when associated with transfusion-related acute lung injury (TRALI), is an indirect cause of ARDS. TRALI is a serious complication that can result from receiving blood products, where the transfused blood causes an immune response leading to pulmonary damage. It indirectly triggers inflammation and fluid buildup in the lungs, contributing to ARDS.

A. treatment plan will need to be changed to achieve the desired effect B. cancer treatment is having, the desired effect on killing cancer cells C. client is at greater risk for tumor lysis syndrome D. cancer has increased size and metastatic sites

Correct Answer is B

Explanation

A) Treatment plan will need to be changed to achieve the desired effect:
The decrease in the carcinoembryonic antigen (CEA) levels from 50 ng/mL to 10 ng/mL suggests that the cancer is responding to the current treatment, not that the treatment plan needs to be changed. A drop in CEA levels typically indicates a positive response to treatment, such as chemotherapy, in reducing the number or size of cancer cells.

B) Cancer treatment is having the desired effect on killing cancer cells:
Carcinoembryonic antigen (CEA) is a tumor marker that is often elevated in individuals with certain cancers, particularly colorectal cancer. A decrease in CEA levels, as noted in this case (from 50 ng/mL to 10 ng/mL), usually signifies that the treatment is successfully targeting the cancer and reducing the tumor burden. This drop suggests that the chemotherapy is effectively killing cancer cells and reducing the size or activity of the tumor.

C) Client is at greater risk for tumor lysis syndrome:
Tumor lysis syndrome typically occurs when large numbers of cancer cells die rapidly, releasing their intracellular contents into the bloodstream, which can lead to metabolic disturbances like hyperkalemia, hyperphosphatemia, and renal failure. It is more common in aggressive hematologic cancers, such as leukemia or lymphoma, and typically presents with a rapid rise in tumor marker levels, not a decrease.

D) Cancer has increased size and metastatic sites:
An increase in tumor size or the development of metastatic sites would typically result in an increase in CEA levels, not a decrease. Since CEA levels have dropped, it is more likely that the cancer is shrinking or responding to the current treatment. This finding is more indicative of a positive response rather than disease progression.

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The nurse is caring for a patient with multiple traumatic injuries following an occupational accident where the patient fell from a 30ft high ladder. Upon assessment, the-nurse hears bowel sounds in the chest. What should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What does the nurse identify as INDIRECT cause of acute respiratory distress syndrome (ARDS) SELECT ALL THAT APPLY

Correct Answer is ["D","E"]

Explanation

The nurse is reviewing lab results for a client receiving chemotherapy for the treatment of cancer. The nurse notes the carcinoembryonic antigen (CEA) was previously 50 ng/ mL and is now 10 ng/mL (normal range 0-2.5 ng/mL) The nurse is aware this finding indicates the:

Correct Answer is B

Explanation

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