A nurse is teaching a client who has flail chest about ways to prevent further respiratory complications. Which of the following statements indicates a need for further teaching?

"I should breathe deeply."

"I should cough frequently."

"I should avoid pain medications as much as possible."

"I should use an incentive spirometer regularly."

Answer and Explanation

The Correct Answer is C

A. "I should breathe deeply."
Deep breathing prevents atelectasis and promotes gas exchange.

B. "I should cough frequently."
Frequent coughing helps clear secretions and prevent pneumonia.

C. "I should avoid pain medications as much as possible."
This is incorrect. Adequate pain control is essential for effective breathing and coughing. Pain medications should not be avoided without cause.

D. "I should use an incentive spirometer regularly."
Incentive spirometry is essential to prevent respiratory complications.

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Free Nursing Study Resources

Correct Answer is ["43.2"]

Explanation

Calculation:
1 kg = 2.2 lbs
95 lbs ÷ 2.2 = 43.18 kg
1 mg/kg × 43.18 = 43.2 mg (rounded to the nearest tenth)

A. Insert a nasogastric (NG) tube. B. Obtain blood cultures. C. Rapidly administer 30 mL/kg of normal saline. D. Measure lactate level. E. Administer broad-spectrum antibiotics. F. Obtain a urine specimen. G. Obtain a wound culture. H. Type and cross-match for 2 units of packed RBCs.

Correct Answer is ["B","C","D","E"]

Explanation

A. Insert a nasogastric (NG) tube.
Not part of the first-hour sepsis bundle; used for gastric decompression or nutrition later if needed.

B. Obtain blood cultures.
Cultures must be drawn before antibiotics to identify the causative organism.

C. Rapidly administer 30 mL/kg of normal saline.
Initial fluid resuscitation is essential to correct hypotension and improve perfusion.

D. Measure lactate level.
Elevated lactate indicates tissue hypoperfusion and helps guide treatment effectiveness.

E. Administer broad-spectrum antibiotics.
Timely antibiotics reduce mortality; must be given within 1 hour.

F. Obtain a urine specimen.
May help identify infection source, but not a priority in the first hour.

G. Obtain a wound culture.
Can be done later; blood cultures are the priority in sepsis.

H. Type and cross-match for 2 units of packed RBCs.
Only needed if there's evidence of hemorrhagic shock or anemia, which is not the case here.

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A nurse is teaching a client who has flail chest about ways to prevent further respiratory complications. Which of the following statements indicates a need for further teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["43.2"]

Explanation

A nurse is caring for a 73-year-old client in the emergency department (ED). Exhibits It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications?

Correct Answer is ["B","C","D","E"]

Explanation

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