The nurse is caring for a client who is 3 hours post-operative following a right lobectomy for lung cancer. The client has shallow respirations at a rate of 14/minute with guarding of the operative site. The breath sounds are diminished throughout the left lung field. The nurse assigns the highest priority to which intervention to prevent acute respiratory failure?

Encourage the daily use of the incentive spirometer

Assisting the client with ambulation in the hallway

Increasing the chest tube suction to 44 mmHg

Assessing for adequate pain relief

Answer and Explanation

The Correct Answer is D

A. Encourage the daily use of the incentive spirometer: While the use of an incentive spirometer is important for improving lung expansion and preventing atelectasis, it may not be effective unless the client’s pain is well-managed. If pain is not addressed first, the client may be unable or unwilling to use the incentive spirometer properly, thus delaying recovery and increasing the risk of respiratory complications.

B. Assisting the client with ambulation in the hallway: Ambulation is an important post-operative activity for improving circulation and preventing complications such as deep vein thrombosis (DVT) or pneumonia. However, the priority at this time should be addressing the client's pain and ensuring adequate breathing before attempting more strenuous activities like ambulation. If the client is in pain and not breathing effectively, ambulation could exacerbate respiratory difficulties..

C. Increasing the chest tube suction to 44 mmHg: Increasing chest tube suction is not indicated unless there is evidence of inadequate drainage or a specific complication, such as a pneumothorax or pleural effusion. In this case, the priority is to address the client’s respiratory function, which is more likely to improve with pain relief, deep breathing, and appropriate positioning. Suctioning should only be adjusted if there is a clinical reason such as signs of a pneumothorax or inadequate drainage, which is not indicated by the information provided.

D. Assessing for adequate pain relief: The most urgent intervention in this scenario is ensuring that the client has adequate pain relief. The client’s shallow respirations and guarding of the operative site suggest that pain is inhibiting effective breathing and deep inspiration, which is crucial for preventing atelectasis and improving ventilation. Pain control is essential in promoting optimal respiratory function, as uncontrolled pain can lead to shallow breathing, reduced lung expansion, and compromised gas exchange, all of which can increase the risk of acute respiratory failure. Once pain is managed, the client will be better able to engage in other respiratory interventions

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Correct Answer is B

Explanation

A. Tizanidine is a sleep aid and used to promote sleep along with melatonin:

This is incorrect. Tizanidine is not classified as a sleep aid. While muscle relaxants like tizanidine may cause drowsiness as a side effect, its primary purpose is to reduce muscle spasms rather than to promote sleep. Using it in combination with melatonin for sleep would not be appropriate unless specifically prescribed by a healthcare provider.

B. Tizanidine is a muscle relaxant medication used to reduce muscle spasms:

Tizanidine is a centrally acting muscle relaxant that is commonly used to treat muscle spasms and spasticity. In clients with amyotrophic lateral sclerosis (ALS), spasticity can be a significant symptom, leading to muscle stiffness and discomfort. Tizanidine helps by relaxing the muscles and alleviating the muscle tightness associated with ALS. It works by inhibiting nerve impulses that cause muscles to contract, thus reducing spasticity and improving mobility. This medication is not intended for sleep promotion or pain relief directly, but rather to manage muscle spasms.

C. Tizanidine is an antibiotic medication used to treat bacterial infections:

This is incorrect. Tizanidine is not an antibiotic and has no role in treating bacterial infections. It is a muscle relaxant used for managing spasticity, not an antimicrobial drug.

D. Tizanidine is an opiate and is used to relieve severe pain:

This is incorrect. Tizanidine is not an opiate and does not belong to the class of opioids. It does not have the pain-relieving effects of opioid analgesics. While it may provide some relief from muscle discomfort, it is not used to treat severe pain in the way opiates like morphine or oxycodone are. Tizanidine’s primary purpose is to address muscle spasticity, not pain management.

A. similar to the angina attacks you had in the past." B. a condition characterized by coronary arteries vasodilating." C. a term used to describe an irregular heartbeat." D. is a less severe type of heart attack compared to STEMI."

Correct Answer is D

Explanation

A. Similar to the angina attacks you had in the past:
This response is not entirely accurate. Angina refers to chest pain that occurs when the heart's demand for oxygen exceeds its supply, usually due to partial blockage of the coronary arteries. NSTEMI (non-ST elevation myocardial infarction) is different from angina in that it involves actual heart muscle injury or damage due to partial or intermittent blockage of a coronary artery, whereas angina does not cause permanent heart muscle damage. Therefore, describing NSTEMI as similar to past angina attacks would be misleading.

B. A condition characterized by coronary arteries vasodilating:
This is incorrect. NSTEMI occurs due to a partial blockage or narrowing of the coronary arteries, usually caused by a blood clot that forms around a ruptured atherosclerotic plaque. The blockage restricts blood flow to the heart muscle, causing injury or infarction. Vasodilation (the widening of blood vessels) is not a characteristic of NSTEMI; in fact, it is the constriction or blockage of the coronary arteries that leads to this type of heart attack.

C. A term used to describe an irregular heartbeat:
This is incorrect. NSTEMI is not related to an irregular heartbeat or arrhythmia directly. While arrhythmias (irregular heartbeats) can occur as a result of a heart attack, NSTEMI specifically refers to a type of heart attack that is not accompanied by the characteristic ST-segment elevation seen on an electrocardiogram (ECG) in a STEMI (ST-elevation myocardial infarction). It indicates a partial blockage of a coronary artery and is generally less severe than STEMI.

D. Is a less severe type of heart attack compared to STEMI:
This is the most accurate response. NSTEMI is a type of heart attack that is often considered less severe than STEMI, but still involves heart muscle injury. The difference between NSTEMI and STEMI lies in the ECG findings: STEMI involves a full-thickness myocardial infarction with a significant blockage of the artery, as indicated by ST-segment elevation on an ECG. In NSTEMI, there is a partial blockage or temporary decrease in blood flow, and the ST-segment does not elevate on the ECG, but biomarkers (like troponin) are elevated, indicating heart muscle damage. NSTEMI is often less severe in terms of the extent of damage compared to STEMI, but it still requires urgent treatment to prevent further complications.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with amyotrophic lateral sclerosis (ALS). The client was given a medical prescription for tizanidine. What information would the nurse provide regarding this medication? Tizanidine is

Correct Answer is B

Explanation

The client tells the nurse, "My physician told me that I had a non-ST elevation myocardial infarction (NSTEMI). " I thought all heart attacks were the same. Can you explain this to me?" The nurse's best response to the client's question would be: "NSTEMI is

Correct Answer is D

Explanation

The nurse is evaluating the effectiveness of teaching the proper use of a metered dose inhaler (MDI) with a spacer. The nurse understands the aching has been effective when the client demonstrates which technique?

What is the first action the nurse should take with the accidental dislodgement of a chest tube?

A client comes to the emergency Department with chest pain and the nurse suspects a myocardial infarction. Which questions) should the nurse ask the client about the pain in the initial assessment? (SELECT ALL THAT APPLY)

The nurse monitors the client in the immediate hours following an anterior-lateral wall myocardial infarction for the development of:

The nurse is caring for a client with respiratory failure. The client is lethargic and slow to follow commands. Current vital signs are: BP 88/52, pulse 132, respirations 8, and SPO2 84% on 35% Venturi mask. The nurse would anticipate which medical prescription?

When caring for a client with a chest tube, the nurse would avoid the practice