The practical nurse (PN) is monitoring a client who was admitted following a motor vehicle collision (MVC). The PN is unable to auscultate breath sounds on the left side, and the healthcare provider is notified. While awaiting the arrival of the healthcare provider, which action should the PN take?

Demonstrate the use of an incentive spirometer.

Monitor the client for increasing respiratory distress.

Administer a PRN dose of a diuretic medication.

Encourage the client to use pursed-lip breathing.

Answer and Explanation

The Correct Answer is B

Choice A reason: Demonstrating the use of an incentive spirometer is a valuable intervention for encouraging deep breathing and preventing atelectasis. However, in the context of a client with absent breath sounds on one side, the priority is to monitor for signs of respiratory distress or complications such as a pneumothorax. While using an incentive spirometer may be beneficial in other scenarios, it is not the immediate priority in this case.
Choice B reason: Monitoring the client for increasing respiratory distress is the most critical action to take. The absence of breath sounds on the left side could indicate a serious complication such as a pneumothorax, hemothorax, or other issues that can compromise respiratory function. By closely monitoring the client, the practical nurse can detect signs of worsening condition, such as increased work of breathing, cyanosis, or changes in vital signs, and provide timely intervention or support while awaiting the healthcare provider's arrival.
Choice C reason: Administering a PRN dose of a diuretic medication is not appropriate in this context. Diuretics are used to manage fluid balance and treat conditions such as heart failure or hypertension but are not relevant for addressing the immediate concern of absent breath sounds and potential respiratory distress. The focus should remain on monitoring the client's respiratory status and ensuring appropriate interventions are available if needed.
Choice D reason: Encouraging the client to use pursed-lip breathing can be beneficial for clients experiencing shortness of breath or for managing chronic obstructive pulmonary disease (COPD). However, in the case of absent breath sounds on one side, it is more important to monitor for signs of respiratory compromise and ensure the client receives prompt medical evaluation and intervention. Pursed-lip breathing is not the immediate priority in this scenario.

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Correct Answer is C

Explanation

Choice A reason: Red meats are typically high in sodium, especially if they are processed or cured. Encouraging the consumption of red meats would not be appropriate for a client with low sodium levels.
Choice B reason: Salted crackers are high in sodium and should be avoided for a client with low sodium levels. Consuming salted crackers would further decrease the sodium level, which is not desirable in this case.
Choice C reason: Fresh fruits are naturally low in sodium and are a good choice for a client with low sodium levels. They provide essential vitamins and nutrients without adding excess sodium to the diet.
Choice D reason: Green vegetables are also low in sodium and are a healthy option for a client with low sodium levels. However, fresh fruits are often more palatable and easier to incorporate into the diet, making them a better choice for encouraging the client to eat.

A. Fat emboli. B. Urinary retention. C. Nonunion. D. Muscular spasms

Correct Answer is A

Explanation

Choice A reason: Fat emboli, or fat embolism syndrome (FES), is the most critical complication to monitor for in a client who had a long bone fracture repaired. This condition occurs when fat droplets from the bone marrow enter the bloodstream and travel to the lungs, brain, or other organs. Symptoms can include respiratory distress, confusion, and a petechial rash. FES can develop within 24 to 72 hours after the injury or surgery and can be life-threatening. Therefore, it is essential to observe for signs such as sudden shortness of breath, rapid breathing, changes in mental status, and the characteristic rash. Early detection and intervention are crucial to manage this potentially severe complication.
Choice B reason: Urinary retention is a possible postoperative complication due to anesthesia or immobility. It is important to monitor urine output and ensure that the client is voiding adequately. However, it is not as immediately life-threatening as a fat embolism. While urinary retention requires attention and management, the practical nurse should prioritize monitoring for signs of fat embolism due to its more severe and acute nature.
Choice C reason: Nonunion refers to the failure of the fracture to heal properly, which can lead to chronic pain and functional impairment. This complication typically develops over a more extended period rather than immediately postoperatively. Monitoring for signs of nonunion, such as persistent pain and lack of healing on follow-up X-rays, is important. However, it is not the most urgent concern in the immediate postoperative period when compared to the risk of a fat embolism.
Choice D reason: Muscular spasms can occur after a fracture as the muscles around the injury site contract to protect and stabilize the affected area. These spasms can be painful and impact the client's comfort and mobility. While it is necessary to address muscle spasms through pain management and physical therapy, they are generally not life-threatening. The practical nurse should focus on monitoring for signs of fat embolism, which poses a more immediate risk to the client's health.

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The practical nurse (PN) is monitoring a client who was admitted following a motor vehicle collision (MVC). The PN is unable to auscultate breath sounds on the left side, and the healthcare provider is notified. While awaiting the arrival of the healthcare provider, which action should the PN take?

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Naxlex Comprehensive Predictor Exams

A client with Crohn's disease has a serum sodium level of 130 mEq/L (130 mmol/L). Which foods should the practical nurse (PN) encourage the client to eat? Reference Range: Sodium: 136 to 145 mEq/L (136 to 145 mmol/L)

Correct Answer is C

Explanation

It is most important for the practical nurse (PN) to observe for which complication when caring for a client who had a long bone fracture repaired yesterday?

Correct Answer is A

Explanation

The most important complication for the practical nurse (PN) to observe for when caring for a client who had a long bone fracture repaired yesterday is:

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