You are a nurse caring for a patient who was just brought into the emergency department after falling off a roof at a construction site. Upon assessment, you note that the patient's respirations are 32/min and the blood pressure is falling. The patient's trachea appears to be right of midline, and the patient's respiratory effort appears to be becoming more and more labored. What is your MOST likely PRIORITY action?

Prepare to administer Albuterol to aid the patient's breathing

Prepare for chest tube insertion

Prepare to apply oxygen via non-rebreather mask at 8L/Min

Sit the patient up in high-fowler's position

Answer and Explanation

The Correct Answer is B

A. Prepare to administer Albuterol to aid the patient's breathing: Albuterol is used for bronchodilation in asthma or COPD. The priority is addressing the potential life-threatening condition, such as a pneumothorax or hemothorax, indicated by the patient's tracheal deviation and labored breathing.

B. Prepare for chest tube insertion: The tracheal deviation, falling blood pressure, and labored breathing suggest a possible tension pneumothorax or hemothorax, both of which require immediate chest tube insertion. This is necessary to relieve pressure in the chest and allow the lungs to re-expand, addressing the respiratory and circulatory distress.

C. Prepare to apply oxygen via non-rebreather mask at 8L/Min: While oxygen is necessary, simply applying oxygen will not resolve the underlying mechanical issue of a tension pneumothorax. The pressure in the chest needs to be relieved for the lung to re-expand and effectively take up oxygen.

D. Sit the patient up in high-fowler's position: While sitting the patient up may help with breathing in some conditions, the most likely cause of the patient’s symptoms is a traumatic injury that requires chest tube insertion, not just positioning.

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Correct Answer is A

Explanation

A. An initial loss of consciousness followed by a coherent period and a subsequent loss of consciousness: An epidural hematoma typically presents with a brief loss of consciousness, followed by a lucid period, then a second loss of consciousness. This pattern is a hallmark sign due to rapid pressure buildup from the blood.

B. Narrowing pulse pressure with tachycardia: Narrowing pulse pressure and tachycardia are not associated with an epidural hematoma. More commonly, widening pulse pressure and bradycardia (Cushing’s triad) are seen in severe cases of increased intracranial pressure.

C. Drainage of clear fluid from the ears and nose: Drainage of clear fluid from the ears and nose may suggest CSF leakage, typically due to a skull fracture. This is not specific to an epidural hematoma, which primarily involves bleeding between the dura and skull.

D. Extensive swelling under the eyes: "Raccoon eyes" can be seen with basal skull fractures, but it is not specific to epidural hematomas. The hallmark manifestation is the consciousness pattern described in option A.

A. "PEEP will prevent lung damage while the patient is on the ventilator." B. “PEEP will push more air into the lungs during inhalation." C. "PEEP prevents the alveoli from collapsing during exhalation" D. "PEEP allows the breathing machine to deliver 100% 02 to the lungs.”

Correct Answer is C

Explanation

A. "PEEP will prevent lung damage while the patient is on the ventilator.": While PEEP helps keep the lungs inflated, it is not specifically aimed at preventing lung damage. Its primary function is to prevent alveolar collapse and improve oxygenation.

B. "PEEP will push more air into the lungs during inhalation.": PEEP does not affect the volume of air delivered during inhalation. It helps keep the alveoli open during exhalation, but does not increase the amount of air pushed into the lungs during inhalation.

C. "PEEP prevents the alveoli from collapsing during exhalation.": PEEP applies pressure to the lungs at the end of exhalation, preventing the alveoli from collapsing, which improves oxygenation by maintaining functional residual capacity and enhancing gas exchange.

D. "PEEP allows the breathing machine to deliver 100% O2 to the lungs.": PEEP does not affect the percentage of oxygen delivered. It works to improve oxygenation by keeping the alveoli open, but the fraction of inspired oxygen (FiO2) is what determines the oxygen concentration delivered by the ventilator.

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Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is caring for a client who has an epidural hematoma following a motor-vehicle crash. Which of the clinical manifestations is expected with an epidural hematoma?

Correct Answer is A

Explanation

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the client's caregiver is accurate?

Correct Answer is C

Explanation

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