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.

Answer and Explanation

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 C

Explanation

C. Uric acid is the end product of purine metabolism, and elevated levels of uric acid in the blood can predispose individuals to gout. In acute gout, there is often a marked increase in serum uric acid levels due to the release of uric acid from the breakdown of purines during the inflammatory process.
A. Chloride level is not directly associated with acute gout.
B. Creatinine kinase (CK) is an enzyme found in various tissues, including muscle tissue. Elevated CK levels are associated with muscle damage or injury, such as in cases of muscle trauma, myocardial infarction, or rhabdomyolysis.
D. Intrinsic factor is a glycoprotein produced by the parietal cells of the stomach that is necessary for the absorption of vitamin B12 in the small intestine.

A. Familiarize themselves with commonly used signed language. B. Obtain a board that uses colored pictures as communication. C. Request an interpreter during the initial assessment. D. Ask a family member to be present during the admission.

Correct Answer is C

Explanation

Request an interpreter during the initial assessment involves requesting the assistance of a qualified sign language interpreter to facilitate communication between the nurse and the client who is deaf. This is generally considered the most appropriate and effective option for ensuring accurate and clear communication during the admission process.

A. It may not be feasible for the nurse to become fluent in sign language immediately, learning commonly used signs can help establish basic communication and demonstrate respect for the client's communication needs. However, relying solely on this option may not be sufficient for complex communication needs or during emergencies.
B. Obtaining a board that uses colored pictures as communication may not fully address the client's needs, especially if they primarily use sign language. This option might be useful as a supplementary aid but may not be the most effective method for initial communication.
D. While having a family member present can be helpful, especially if they are proficient in sign language, it may not always be feasible or reliable. Additionally, relying on family members for interpretation can compromise the client's privacy and confidentiality, as well as potentially introduce biases or misunderstandings in communication.

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A nurse is caring for a client who has a flail chest. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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