A nurse is caring for a client who has a flail chest. Which of the following actions should the nurse take?
Provide humidified oxygen.
Administer antibiotic medication.
Implement fluid restriction
Administer acetaminophen orally.
The Correct Answer is A
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.
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Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"C"},"E":{"answers":"C"}}
Explanation
Liver cirrhosis interferes with the synthesis of clotting factors in the liver leading to bleeding as evidence by the spontaneous bruises
The development of ascites occurs as the cirrhotic process progresses leading to increased extravasation of fluid in the splanchnic circulation.
Increased albumin indicates that the synthetic role of the liver is improving. Albumin is synthesized in the liver parenchyma.
Hematemesis occurs due to the presence of esophageal varices as a complication of advanced liver cirrhosis
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Correct Answer is B
Explanation
B. Seizures can result in sudden and uncontrollable movements, which may increase the risk of injury if the client strikes against the side rails of the bed during a seizure episode. Padding the upper two side rails helps minimize the risk of injury by providing a softer surface.
A. Maintaining peripheral IV access ensures that these medications can be administered promptly. However, other routes such as rectal can also be used therefore not a priority
C. Assisting personnel should not be trained in the proper application of restraints as it is not within the scope of their practice.
D. Introduction of objects during a seizure is not recommended as it increases the risk of injury.
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