The nurse is assessing the respiratory status of a client who has suffered a fractured rib. Which observation, if made by the nurse, would not be directly related to the fractured rib?

Pleural effusion on the unaffected side

Shallow breathing due to pain

Guarding behavior when taking deep breaths

Localized chest pain on inspiration

Answer and Explanation

The Correct Answer is A

A. Pleural effusion on the unaffected side is not directly related to a fractured rib. While rib fractures can lead to complications such as pneumothorax or hemothorax, pleural effusion on the opposite side is likely caused by another condition, such as infection or malignancy, and should be investigated separately.

B. Shallow breathing due to pain is a common response to a fractured rib, as the client may avoid deep breaths to minimize discomfort.

C. Guarding behavior when taking deep breaths is directly related to the pain caused by the fractured rib and is an expected observation.

D. Localized chest pain on inspiration is a hallmark symptom of a fractured rib, as the injury causes discomfort with chest wall movement during breathing.

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Correct Answer is C

Explanation

A. While ensuring that a client with an inguinal hernia voids before discharge is important, it does not warrant immediate intervention unless there are signs of urinary retention or other complications.

B. Refusing to deep breathe after an open cholecystectomy can increase the risk of postoperative complications like atelectasis, but it does not require immediate intervention unless there are signs of respiratory distress or infection.

C. Pain on inspiration in a client with deep vein thrombosis (DVT) is a potential sign of pulmonary embolism (PE), a life-threatening complication. Immediate assessment and intervention are critical to prevent further deterioration.

D. Refusing to turn for three hours increases the risk of pressure injuries, but this is not as urgent as the potential for a pulmonary embolism. The nurse should address this issue promptly but not before assessing the client with possible PE.

A. Administer bronchodilator medication before the procedure B. Restrict fluid intake before the procedure C. Perform deep breathing exercises after the procedure D. Place the patient in a supine position during the procedure

Correct Answer is A

Explanation

A. Administering a bronchodilator before postural drainage helps open the airways, making it easier to mobilize and clear secretions during the procedure. This improves the effectiveness of the therapy.

B. Restricting fluid intake before the procedure is not appropriate. Adequate hydration is essential to thin secretions, making them easier to clear during postural drainage.

C. While deep breathing exercises are beneficial for lung expansion and oxygenation, they are not specifically required immediately after postural drainage. The focus is on clearing secretions during the procedure.

D. The supine position is not ideal for postural drainage. The client should be placed in specific positions depending on the lung segment being targeted, such as Trendelenburg or lateral decubitus positions, to facilitate drainage by gravity.

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The nurse is assessing the respiratory status of a client who has suffered a fractured rib. Which observation, if made by the nurse, would not be directly related to the fractured rib?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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