A nurse is caring for a client who has a pneumothorax. The nurse is reviewing the client’s medical record.
What prescriptions should the nurse anticipate for a client who has a pneumothorax?
Thoracentesis.
Obtain ABGs.
Computed tomography (CT) of the chest.
Prepare for insertion of a chest tube.
Obtain intravenous access.
Pulmonary Function Tests (PFTS). .
Correct Answer : A,B,C,D,E
Choice A rationale
Thoracentesis may be performed to remove air from the pleural space in a client with a pneumothorax.
Choice B rationale
Obtaining arterial blood gases (ABGs) can help assess the client’s respiratory status and the severity of the pneumothorax.
Choice C rationale
A computed tomography (CT) scan of the chest can provide detailed images of the lungs and can help confirm the diagnosis of a pneumothorax.
Choice D rationale
Preparation for the insertion of a chest tube may be necessary to remove air from the pleural space and allow the lung to re-expand in a client with a pneumothorax.
Choice E rationale
Obtaining intravenous access is often necessary for administering medications and fluids.
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Correct Answer is B
Explanation
Choice A rationale
While ensuring that nurses demonstrate competency by passing a medication administration test is important, it is not the first step in developing a program to decrease medication administration errors. This strategy focuses on the individual skills of the nurses, but does not address the systemic issues that may have contributed to the errors.
Choice B rationale
Reviewing the circumstances leading up to each medication error is the first step in understanding why the errors occurred. This process allows the committee to identify patterns and common factors that contribute to errors. It is a crucial step in the development of effective strategies to prevent future errors.
Choice C rationale
Developing a quality improvement program for nurses involved in medication errors is a strategy that could be implemented after understanding the root causes of the errors. This approach ensures that the program addresses the specific issues that led to the errors.
Choice D rationale
Conducting an in-service training on medication administration for all nurses is a valuable strategy for preventing medication errors. However, it should be based on the findings from the review of the circumstances leading up to each error. Therefore, it is not the first strategy to consider.
Correct Answer is C
Explanation
Choice A rationale
While the application of anti-embolism stockings can be beneficial in preventing deep vein thrombosis in postoperative patients, it is not the most prioritized nursing intervention in the immediate postoperative period for a patient who has undergone a left pneumonectomy. The immediate postoperative period after a pneumonectomy is critical for monitoring and managing potential complications such as respiratory distress, hemorrhage, and bronchopleural fistula.
Choice B rationale
The use of the incentive spirometer is an important nursing intervention for postoperative patients to promote lung expansion and prevent atelectasis. However, in the immediate postoperative period following a pneumonectomy, the priority is to monitor for complications and ensure the stability of the patient.
Choice C rationale
Assessment of the chest tube and pleur-evac is the most prioritized nursing intervention in the immediate postoperative period for a patient who has undergone a left pneumonectomy. After a pneumonectomy, a chest tube is placed to drain air, blood, and fluid from the pleural space to allow the remaining lung to re-expand. It is crucial to monitor the chest tube system for proper functioning and to assess for complications such as excessive bleeding, infection, or pneumothorax.
Choice D rationale
Repositioning the patient in bed is a standard nursing intervention in postoperative care to enhance comfort, promote lung expansion, and prevent complications such as pressure ulcers and deep vein thrombosis. However, it is not the most prioritized intervention in the immediate postoperative period following a pneumonectomy, where monitoring for respiratory complications and ensuring the stability of the patient are paramount.
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