A nurse is caring for a client who has a pneumothorax.
A nurse is reviewing the client's medical record. Which of the following prescriptions should the nurse anticipate for a client who has a pneumothorax?
For each potential provider's prescription, click to specify if the potential prescription is anticipated, non-essential, or contraindicated for the client.
Obtain intravenous access
Thoracentesis
Pulmonary Function Tests (PFTS)
Prepare for insertion of a chest tube.
Obtain ABGS
Computed tomography (CT) of the chest
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
- Obtain intravenous access: Anticipated: Essential for administering medications, fluids, and potential emergency treatments.
- Thoracentesis: Non-essential: Typically used for pleural effusions, not primary treatment for pneumothorax; chest tube insertion is the main treatment.
- Pulmonary Function Tests (PFTs): Non-essential: Useful for diagnosing chronic respiratory conditions but not a primary intervention for pneumothorax.
- Prepare for insertion of a chest tube: Anticipated: A chest tube is often necessary to re-expand the lung and treat a significant pneumothorax.
- Obtain ABGs: Anticipated: Important for assessing the client’s oxygenation and acid-base balance due to respiratory distress.
- Computed tomography (CT) of the chest: Anticipated: CT can be used to diagnose the extent of the pneumothorax and guide treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Atelectasis is incorrect. Atelectasis refers to lung collapse, which presents as reduced breath sounds and hypoxemia, not abnormal chest movement during respiration.
B. Flail chest is correct. Flail chest is characterized by paradoxical chest movement where a segment of the chest wall moves inward during inspiration and outward during expiration.
C. Pneumothorax is incorrect. Pneumothorax would cause sudden chest pain and dyspnea, but does not cause paradoxical chest movement.
D. Hemothorax is incorrect. Hemothorax involves blood in the pleural space and would cause reduced breath sounds and signs of shock, but not paradoxical chest movement.
Correct Answer is D
Explanation
A. Increasing the rate to 250 mL/hr is not appropriate as it could lead to fluid overload or worsen the client’s condition.
B. Slowing the rate to 20 mL/hr may be too low for maintaining adequate hydration or treatment needs in the context of a head injury.
C. Slowing the rate to 50 mL/hr is not indicated unless there is a specific reason to decrease the fluid rate based on clinical conditions, which is not stated here.
D. Continuing the rate at 125 mL/hr is appropriate for maintaining the current IV fluid regimen unless there are specific orders or conditions that require a change.
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