A client who is admitted to the emergency department (ED) following a motorcycle collision is having difficulty breathing. While assessing the client's chest and lungs, the nurse notes that there are no breath sounds over the left lung fields. Which action(s) should the nurse implement? Select all that apply.

Apply a high-flow oxygen by face mask.

Obtain a chest tube insertion kit.

Withhold narcotic pain medication.

Elevate the head of the bed 45 degrees.

Place client in Trendelenburg position.

Answer and Explanation

The Correct Answer is A

A. Apply high-flow oxygen by face mask. The client is in respiratory distress with absent breath sounds over the left lung field, which is highly suggestive of a pneumothorax or hemothorax. High-flow oxygen helps improve oxygenation while preparing for definitive intervention. In cases of tension pneumothorax, oxygen can help reduce hypoxia until a chest tube or needle decompression is performed.
B. Obtain a chest tube insertion kit. Absent breath sounds on one side following chest trauma strongly suggest a pneumothorax or hemothorax, requiring immediate chest tube placement to re-expand the lung and restore normal ventilation. The nurse should ensure that the equipment for thoracostomy (chest tube insertion) is readily available for the healthcare provider.
C. Withhold narcotic pain medication. Pain control is important in trauma patients, as uncontrolled pain can lead to shallow breathing, atelectasis, and respiratory complications. Narcotics should be used cautiously in clients with respiratory distress, but they are not contraindicated if given at appropriate doses with close monitoring.
D. Elevate the head of the bed 45 degrees. Clients with respiratory distress should be positioned with the head of the bed elevated to improve lung expansion. However, in a suspected pneumothorax, the priority is oxygenation and chest tube insertion. If there is hemodynamic instability, the client may require a flat or semi-Fowler’s position instead.
E. Place client in Trendelenburg position. The Trendelenburg position (head down, feet up) is not appropriate in chest trauma patients. This position can increase intra-abdominal pressure, worsen breathing difficulty, and impair lung expansion. It is typically avoided in clients with respiratory distress or suspected pneumothorax.

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Correct Answer is D

Explanation

A. Prepare to give phenytoin IV as prescribed. Phenytoin is used for seizure prophylaxis in clients with moderate to severe head injuries (GCS ≤ 8–10). A GCS score of 14 indicates mild head injury, and prophylactic anticonvulsants may not be necessary unless ordered for specific risk factors.
B. Perform a substernal rub to evoke a response to pain. A substernal rub (painful stimulus) is used to assess response in unconscious or unresponsive clients (GCS ≤ 8). With a GCS of 14, the client is alert or nearly fully conscious, making a painful stimulus unnecessary and inappropriate.
C. Promptly notify the healthcare provider (HCP) of the GCS score. A GCS of 14 is not a critical or emergency finding, as it indicates mild neurological impairment. While the HCP should be updated on significant changes, routine monitoring is sufficient unless deterioration occurs.
D. Continue monitoring the client's GCS score every 2 hours. Frequent neurological assessments are crucial in head injury management to detect worsening conditions like increasing intracranial pressure (ICP) or cerebral edema. Monitoring the GCS every 2 hours ensures timely intervention if the client’s condition changes.

A. Suture removal kit. B. Suction catheter. C. Sterile gauze dressing. D. Sterile piston syringe.

Correct Answer is C

Explanation

A. Suture removal kit. A suture removal kit is used when the chest tube is ready for removal, but it is not necessary to keep at the bedside during routine chest tube management. The priority is ensuring emergency supplies are available if the tube becomes dislodged.
B. Suction catheter. A suction catheter is used to remove secretions from the airway but is not essential for managing a chest tube. Chest drainage systems function independently to remove air or fluid, and routine suctioning is not required for chest tube management.
C. Sterile gauze dressing. If the chest tube accidentally dislodges, an occlusive dressing (such as sterile gauze with petroleum jelly) should be applied immediately to prevent air from re-entering the pleural space, which could lead to a tension pneumothorax. Keeping sterile gauze at the bedside ensures rapid intervention in case of accidental chest tube removal.
D. Sterile piston syringe. A sterile piston syringe is used for irrigating wounds or suctioning secretions, but it is not necessary for chest tube management. The closed drainage system should never be manually flushed unless specifically ordered by a healthcare provider.

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Naxlex Comprehensive Predictor Exams

The nurse is completing a neurological assessment on a client with a head injury. The Glasgow Coma Scale (GCS) score is 14. Which intervention should the nurse implement?

Correct Answer is D

Explanation

A client has a chest tube connected to a closed water-seal drainage system with suction. Which equipment should the nurse always have available at the client's bedside?

Correct Answer is C

Explanation

The nurse is administering low dose dopamine to a client who is in septic shock. Which physiologic parameter should the nurse use to evaluate a therapeutic response to the dopamine?

A client who had gastric bypass surgery 3 days ago is admitted to the intensive care unit (ICU) with shortness of breath and chest pain. The client has a 100% nonrebreather mask with an oxygen saturation of 88%. Which intervention should the nurse implement?

Exhibits Which are three goals of therapy for this client?

A client is admitted to the intensive care unit (ICU) with sepsis and acute respiratory distress syndrome (ARDS). The client is orally intubated and mechanically ventilated. Which intervention is most important for the nurse to include in the client's plan of care (POC)?

Exhibits Based on the client's laboratory values at 1600, which are appropriate nursing actions? Select all that apply.

Exhibits Click to mark whether the actions are indicated, contraindicated, or nonessential for this client. Each row must have one option selected.