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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Supporting the feet with a rolled pillow helps prevent foot drop (a common issue in hemiplegia). It maintains the ankle in a neutral position, preventing contractures.
A. When lying on the stomach (prone position), the neck should be neutral (neither flexed nor extended). Flexing the neck backward can strain the cervical spine and compromise airway alignment.
C. For a client with right-sided hemiplegia, the affected leg (right leg) should be supported to prevent foot drop.
D. A thick pillow under the head can cause neck hyperextension.
The head should be supported with a small, firm pillow to maintain a neutral neck position.
Correct Answer is A
Explanation
A. Neurovascular assessment should be the nurse's priority assessment. Postoperative patients, especially those who have undergone orthopedic surgery such as ORIF of the femur, are at risk for neurovascular compromise due to factors such as positioning during surgery, edema, and postoperative pain.
B. Pain assessment is important for overall patient comfort and well-being, but in the immediate postoperative period following ORIF of the femur, neurovascular assessment takes priority.
C. The Braden scale is used to assess a patient's risk for pressure ulcers. While pressure ulcer risk assessment is important for overall patient care, it is not the priority assessment for a patient who is postoperative following ORIF of the femur.
D. The Morse Fall Risk scale is used to assess a patient's risk for falls. While fall risk assessment is important for patient safety, it is not the priority assessment for a patient who is postoperative following ORIF of the femur.
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