Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has a flail chest. Which of the following actions should the nurse take?
A. Provide humidified oxygen.
Clients with flail chest often experience compromised respiratory function due to the paradoxical movement of the chest wall. Providing humidified oxygen can help improve oxygenation and maintain airway patency, especially if the client is experiencing hypoxia.
B. Administer antibiotic medication.
Administering antibiotic medication is not a primary intervention for a flail chest unless there is evidence of an associated infection, such as pneumonia
C. Implement fluid restriction
Fluid restriction is not typically indicated for a client with a flail chest unless there are specific indications, such as heart failure or renal dysfunction.
D. Administer acetaminophen orally.
While managing pain is important, flail chest often requires more aggressive pain management strategies, such as opioid analgesics or regional anesthesia, especially if the pain is severe and affects respiratory effort. Acetaminophen alone may not be sufficient for effective pain control in this situation.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Adult Medical Surgical 2023 Proctored Exam. Take the full exam now
Full Explanation
A. Clients with flail chest often experience compromised respiratory function due to the paradoxical movement of the chest wall. Providing humidified oxygen can help improve oxygenation and maintain airway patency, especially if the client is experiencing hypoxia.
B. Administering antibiotic medication is not a primary intervention for a flail chest unless there is evidence of an associated infection, such as pneumonia
C. Fluid restriction is not typically indicated for a client with a flail chest unless there are specific indications, such as heart failure or renal dysfunction.
D. While managing pain is important, flail chest often requires more aggressive pain management strategies, such as opioid analgesics or regional anesthesia, especially if the pain is severe and affects respiratory effort. Acetaminophen alone may not be sufficient for effective pain control in this situation.
Similar Questions
A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care?
A. Place the client in a supine position.
Placing the client in a supine position is not recommended for acute pancreatitis because it can exacerbate pain and discomfort.
B. Administer antihypertensive medications.
The priority in acute pancreatitis is to address pain, manage complications such as fluid imbalances or infections, and support pancreatic rest.
C. Monitor the client for hypercalcemia.
Hypercalcemia can occur as a complication of acute pancreatitis due to calcium mobilization from damaged pancreatic cells. However, keeping the client NPO is priority.
D. Maintain the client on NPO status.
NPO status is typically implemented in the initial management of acute pancreatitis to rest the pancreas and reduce pancreatic enzyme secretion, which can exacerbate inflammation and tissue damage. Nutritional support may be gradually reintroduced once the client's condition stabilizes and symptoms improve.
Full Explanation
D. NPO status is typically implemented in the initial management of acute pancreatitis to rest the pancreas and reduce pancreatic enzyme secretion, which can exacerbate inflammation and tissue damage. Nutritional support may be gradually reintroduced once the client's condition stabilizes and symptoms improve.
A. Placing the client in a supine position is not recommended for acute pancreatitis because it can exacerbate pain and discomfort.
B. The priority in acute pancreatitis is to address pain, manage complications such as fluid imbalances or infections, and support pancreatic rest.
C. Hypercalcemia can occur as a complication of acute pancreatitis due to calcium mobilization from damaged pancreatic cells. However, keeping the client NPO is priority.
A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?
A. Administer oxygen to the client.
The client's symptoms of chills, lower back pain, and nausea suggest a potential transfusion reaction rather than respiratory compromise.
B. Collect a urine sample.
Collecting a urine sample may be indicated to assess for hemolysis or kidney injury, which can occur as a result of a transfusion reaction. However, this action can be deferred until after immediate interventions to manage the suspected reaction.
C. Stop the infusion.
Suspending the infusion of packed RBCs is essential to prevent further administration of the blood product that may be causing the adverse reaction. Stopping the infusion allows for further assessment and appropriate management of the client's symptoms.
D. Check the client's vital signs.
While checking the client's vital signs is important in assessing the severity of the reaction and the client's overall condition, it is not the first action to take when a transfusion reaction is suspected.
Full Explanation
C. Suspending the infusion of packed RBCs is essential to prevent further administration of the blood product that may be causing the adverse reaction. Stopping the infusion allows for further assessment and appropriate management of the client's symptoms.
A. The client's symptoms of chills, lower back pain, and nausea suggest a potential transfusion reaction rather than respiratory compromise.
B. Collecting a urine sample may be indicated to assess for hemolysis or kidney injury, which can occur as a result of a transfusion reaction. However, this action can be deferred until after immediate interventions to manage the suspected reaction.
D. While checking the client's vital signs is important in assessing the severity of the reaction and the client's overall condition, it is not the first action to take when a transfusion reaction is suspected.
A home health nurse is assessing a client who has pernicious anemia. Which of the following is an expected manifestation that poses a risk to the client's safety?
A. Loss of hearing
Loss of hearing is not typically associated with pernicious anemia.
B. Muscle wasting
Muscle wasting is not a typical manifestation of pernicious anemia. However, weakness and fatigue are common symptoms due to anemia resulting from decreased oxygen-carrying capacity of the blood.
C. Paresthesia
Paresthesia, or abnormal sensations like tingling, numbness, or burning, is a common neurological manifestation of pernicious anemia due to damage to the peripheral nerves caused by vitamin B12 deficiency. Paresthesia can affect balance and coordination, increasing the risk of falls and injuries, and thus posing a risk to the client's safety.
D. Changes in vision
While changes in vision can impact the client's safety, they are not as directly associated with pernicious anemia as paresthesia, which affects mobility and balance.
Full Explanation
C. Paresthesia, or abnormal sensations like tingling, numbness, or burning, is a common neurological manifestation of pernicious anemia due to damage to the peripheral nerves caused by vitamin B12 deficiency. Paresthesia can affect balance and coordination, increasing the risk of falls and injuries, and thus posing a risk to the client's safety.
A. Loss of hearing is not typically associated with pernicious anemia.
B. Muscle wasting is not a typical manifestation of pernicious anemia. However, weakness and fatigue are common symptoms due to anemia resulting from decreased oxygen-carrying capacity of the blood.
D. While changes in vision can impact the client's safety, they are not as directly associated with pernicious anemia as paresthesia, which affects mobility and balance.