A nurse is assisting the provider to care for trauma patient who has been diagnosed with a hemothorax. Which of the following actions should the nurse perform first to treat this cause of obstructive shock?

Prepare for chest tube insertion

Chart assessment findings

Administer lorazepam

Initiate IV fluid resuscitation

Answer and Explanation

The Correct Answer is A

A) Prepare for chest tube insertion:
The priority treatment for a hemothorax, which is a collection of blood in the pleural space, is to address the loss of intravascular volume and to relieve the pressure on the lungs. The insertion of a chest tube is the first step in draining the blood and restoring proper lung function and ventilation. This intervention directly addresses the cause of obstructive shock (increased pressure on the lungs and impaired cardiac output) by re-expanding the lung and preventing further complications such as respiratory distress or cardiovascular collapse.

B) Chart assessment findings:
While accurate documentation of the patient's condition is important for ongoing care and legal purposes, it is not the priority action in this situation. Immediate treatment to address the hemothorax, such as chest tube insertion, takes precedence over documentation. Charting should be done after stabilizing the patient.

C) Administer lorazepam:
Lorazepam is an anxiolytic medication that might be used for anxiety or agitation, but it is not an immediate priority in this situation. The patient's life-threatening condition (hemothorax) needs to be addressed first, and sedation or anxiety management should be considered once the patient is stabilized and receiving appropriate interventions.

D) Initiate IV fluid resuscitation:
While fluid resuscitation is essential in trauma patients with hypovolemic shock, the primary concern in hemothorax is relieving the intrathoracic pressure by draining the blood from the pleural space. IV fluid resuscitation should be initiated shortly after or simultaneously with the chest tube insertion, but addressing the hemothorax directly is the first priority in treating obstructive shock.

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Correct Answer is B

Explanation

A) Ondansetron and Metoclopramide:
Ondansetron is an antiemetic used to prevent nausea and vomiting, and Metoclopramide is a medication that promotes gastric emptying and is often used to treat nausea and gastroesophageal reflux. Neither of these medications are typically associated with ototoxicity. Ototoxicity is more commonly seen with medications that affect the inner ear or auditory pathways, particularly those that are used in high doses or over extended periods.

B) Aspirin and ibuprofen:
Both aspirin (a nonsteroidal anti-inflammatory drug, NSAID) and ibuprofen are associated with ototoxicity, especially when used in high doses or over prolonged periods. Ototoxicity from NSAIDs can result in symptoms such as tinnitus (ringing in the ears) or even hearing loss. This occurs due to their impact on the cochlea and auditory nerve.

C) Metoprolol and Furosemide:
Metoprolol is a beta-blocker used for managing hypertension, heart failure, and other cardiovascular conditions, and Furosemide is a diuretic often used to treat conditions such as heart failure and edema. Neither of these drugs is typically associated with ototoxicity. However, high doses of furosemide, particularly when given rapidly or intravenously, may be associated with transient hearing loss.

D) Pantoprazole and Docusate Sodium:
Pantoprazole is a proton pump inhibitor (PPI) used to treat gastrointestinal issues like acid reflux and ulcers. Docusate sodium is a stool softener used to treat constipation. Neither of these medications is known to cause ototoxicity. These drugs generally do not affect hearing or the auditory system.

A. Assess lung sounds and respiratory rate at least every 2 hours B. Assess and document pain level once every shift C. Maintain sequential compression device (SCD's) while in bed D. Elevate the head of the bed ten degrees

Correct Answer is A

Explanation

A) Assess lung sounds and respiratory rate at least every 2 hours:
In a patient with Myasthenia Gravis (MG) who has undergone thymectomy, monitoring respiratory status is critical. MG is a neuromuscular disorder that can lead to respiratory muscle weakness, which may be exacerbated post-operatively. Assessing lung sounds and respiratory rate at least every 2 hours is crucial to detect early signs of respiratory compromise, including hypoventilation or atelectasis.

B) Assess and document pain level once every shift:
While pain assessment is important, especially after a thymectomy, this action alone does not directly address the immediate issue of ineffective breathing patterns. In patients with MG, respiratory complications are a priority concern. Pain management should be part of the overall plan of care, but it is secondary to monitoring respiratory function in the acute post-operative period. Pain can affect respiratory effort, but it should be managed in the context of more pressing issues like airway and breathing assessment.

C) Maintain sequential compression device (SCD's) while in bed:
While SCDs are important in preventing deep vein thrombosis (DVT) in patients who are immobile, they are not the most appropriate intervention for a client with ineffective breathing patterns. The primary concern in a post-thymectomy patient with MG is respiratory function.

D) Elevate the head of the bed ten degrees:
While elevating the head of the bed can help with comfort and potentially improve ventilation in some patients, it is not the most specific or effective intervention for managing ineffective breathing patterns in a patient with MG. For optimal respiratory function, it is typically more beneficial to elevate the head of the bed to a higher degree (e.g., 30-45 degrees) to enhance lung expansion, rather than just 10 degrees.

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A nurse is assisting the provider to care for trauma patient who has been diagnosed with a hemothorax. Which of the following actions should the nurse perform first to treat this cause of obstructive shock?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which commonly prescribed is does the nurse identify as ototoxic?

Correct Answer is B

Explanation

The nurse is caring for a client diagnosed with Myasthenia Gravis (MG) who is post op thymectomy. The client problem is Ineffective Breathing Pattern, Which action would the nurse include in the plan of care?

Correct Answer is A

Explanation

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