A patient is admitted to the respiratory unit with flail chest.
Which answer best describes this diagnosis?
A condition in which there is a puncture or rupture of the lung.
A condition characterized by the presence of air or gas in the pleural cavity.
A condition characterized by multiple fractures of the ribs resulting in a segment of the chest wall becoming detached.
A condition characterized by the collapse of the lung.
The Correct Answer is C
Choice A rationale
A puncture or rupture of the lung is typically associated with a pneumothorax, not flail chest. Pneumothorax occurs when air leaks into the space between the lung and the chest wall.
Choice B rationale
The presence of air or gas in the pleural cavity is known as pneumothorax. Flail chest, however, is characterized by multiple rib fractures.
Choice C rationale
Flail chest occurs when multiple adjacent ribs are fractured in multiple places, creating a free-floating segment of the chest wall. This condition is serious and often results from blunt chest trauma.
Choice D rationale
The collapse of the lung is known as atelectasis or pneumothorax, not flail chest. Flail chest specifically refers to the detachment of a segment of the rib cage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Increasing fluid intake is contraindicated in clients with fluid overload, such as those with bilateral lower extremity edema and lung crackles. It can worsen the condition.
Choice B rationale
Administering prescribed diuretics is the priority intervention to reduce fluid overload in clients with heart failure post-STEMI. It helps to decrease edema and pulmonary congestion.
Choice C rationale
Applying warm compresses to the lower extremities may provide temporary relief but does not address the underlying issue of fluid overload.
Choice D rationale
Encouraging ambulation is beneficial for overall health but is not a priority intervention for managing fluid overload in this context. .
Correct Answer is C
Explanation
Choice A rationale
Hypokalemia is a potential concern with diuretic therapy, but not with hypertonic saline solution (3% NaCl) administration for hyponatremia.
Choice B rationale
Hypovolemia is less likely to occur with hypertonic saline infusion. The main concern is overcorrection leading to fluid overload.
Choice C rationale
Fluid overload is a significant risk when administering hypertonic saline (3% NaCl). Nurses should closely monitor for signs of fluid overload, such as edema, crackles in the lungs, and increased blood pressure.
Choice D rationale
Hypernatremia is a possible complication of hypertonic saline administration, but it is not as immediate a concern as fluid overload. Monitoring for fluid overload should take precedence.
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