The nurse is receiving report on their patient assignments for the day. Which patient should be assessed first? The patient...
who reports a change in pattern of their usual shortness of breath
reports flank pain 7 on a (0-10) scale 15 min after getting an oral analgesic
with serosanguinous drainage in a JP drain post op day 3.
bilateral wheezes after walking 40 feet (12 meters), pulse ox 96 on RA
The Correct Answer is A
A. A change in the pattern of shortness of breath can be a sign of worsening respiratory or cardiovascular status and may indicate a serious condition such as pulmonary embolism, heart failure, or a pneumothorax. This requires immediate assessment and further investigation to determine the cause.
B. While flank pain (7/10) after receiving oral analgesic could be concerning, the fact that the pain is still significant 15 minutes after medication administration suggests that the pain may not yet be well-controlled. However, this is not as immediately urgent as a change in breathing pattern, so this patient should be assessed after the one with respiratory concerns.
C. Serosanguinous drainage from a JP drain on postoperative day 3 is not uncommon, and this typically does not require immediate intervention unless the drainage increases significantly or becomes more sanguine. This patient should be assessed after the one with a change in shortness of breath.
D. Bilateral wheezes after walking 40 feet, with a pulse oximetry of 96% on room air, is concerning but not as urgent as a change in shortness of breath. The pulse oximetry is within the normal range, and wheezing could be related to mild exertion or an underlying chronic condition (like asthma), but the patient’s condition doesn’t seem to be immediately life-threatening. This patient should be assessed after the patient with shortness of breath.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Inserting an oral airway may be appropriate if the client is biting the endotracheal tube, but in this scenario, the cause of the low-pressure alarm is unknown and could be due to disconnection or a leak — a more urgent issue requiring immediate action.
B. Suctioning and resetting the alarm could delay appropriate ventilation if the issue is a disconnection or leak; it’s not the priority intervention in an unclear emergency.
C. When the source of a low-pressure alarm (which often indicates a leak or disconnection) cannot be identified and the client’s ventilation status is in question, the nurse should immediately disconnect the client from the ventilator and manually ventilate with a bag-valve mask to ensure oxygenation until the issue is resolved.
D. Notifying the respiratory therapist and provider is appropriate after immediate interventions are performed to maintain the patient’s airway and oxygenation.
Correct Answer is ["A","B","D","E"]
Explanation
A. Endotracheal tube is in the right bronchus: If the endotracheal tube is inadvertently inserted too far and enters the right bronchus, it can cause a high-pressure alarm because it limits airflow to the left lung and creates an obstruction in the right bronchus. This would cause increased resistance to ventilation.
B. Kink in ventilator tubing: A kink in the tubing increases resistance and makes it harder for the ventilator to push air through, which can trigger a high-pressure alarm. This should be checked promptly as it can impede ventilation.
C. Prescribed tidal volume is not sufficient: If the tidal volume is too low for the patient’s needs, it is more likely to cause inadequate ventilation, but it does not directly trigger a high-pressure alarm. A low tidal volume typically leads to hypoventilation or inadequate gas exchange rather than increased pressure.
D. Pneumothorax: A pneumothorax can cause increased pressure in the chest and make it difficult for the ventilator to deliver air, potentially triggering a high-pressure alarm. This is a serious complication that requires immediate assessment.
E. Secretions in the endotracheal tube: Secretions in the tube can obstruct airflow, increasing airway resistance, which can trigger a high-pressure alarm. Suctioning to clear the secretions is needed.
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