You are caring for a patient in the ED who came in after a hard tackle in a football game. The x-rays show that he has a fracture of 2 ribs on the right side. Which intervention will the nurse expect for this patient?

Mechanical ventilation

Prepare for a chest tube

Needle decompression

Intercostal nerve block for pain management

Answer and Explanation

The Correct Answer is D

Choice A reason:

Mechanical ventilation is not typically required for patients with rib fractures unless there is severe respiratory compromise or other underlying issues that necessitate ventilatory support.

Choice B reason:

Preparing for a chest tube is not generally required for isolated rib fractures unless there is an associated pneumothorax or hemothorax. Chest tubes are used to manage complications that involve air or blood in the pleural space.

Choice C reason:

Needle decompression is performed in emergencies to relieve tension pneumothorax. This procedure is not indicated for simple rib fractures without evidence of a tension pneumothorax.

Choice D reason:

An intercostal nerve block for pain management is an appropriate intervention for a patient with rib fractures. It helps control pain, allowing the patient to breathe deeply and cough effectively, which is important for preventing complications such as pneumonia.

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Correct Answer is C

Explanation

Choice A reason:

Assessing the level at which the client has intact sensation is important in the overall management of a spinal cord injury. However, it is not the immediate priority in an emergency setting. Ensuring the client's respiratory function and oxygenation is the first concern to stabilize the patient.

Choice B reason:

Determining the level at which the client has retained mobility is part of the assessment of a spinal cord injury but is secondary to monitoring and ensuring adequate respiratory effort and oxygen saturation. Mobility can be evaluated once the patient's vital signs are stable.

Choice C reason:

Monitoring respiratory effort and oxygen saturation level is the priority nursing action for a client with a spinal cord injury at the C3 to C4 level. Injuries at this level can impair the diaphragm and other muscles essential for breathing. Ensuring that the patient has adequate respiratory function and oxygenation is critical to prevent respiratory failure.

Choice D reason:

Checking blood pressure and pulse for signs of spinal shock is important, but the immediate priority is to ensure that the patient is breathing effectively and has sufficient oxygen saturation. Respiratory compromise can occur quickly with high-level spinal cord injuries, making it the most urgent concern.

A. Elevate the client's head on two pillows B. Decrease the noise level in the client's room C. Suction the endotracheal tube frequently D. Administer a stool softener E. Give a 500cc NS fluid bolus

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

Explanation

Choice A reason:

Elevating the client's head on two pillows is not a standardized method for managing intracranial pressure. Instead, elevating the head of the bed to 30 degrees is a more effective strategy to promote venous drainage and reduce ICP.

Choice B reason:

Decreasing the noise level in the client's room helps create a calm environment, which can reduce stress and prevent increases in ICP. Excessive noise and stimulation can elevate intracranial pressure.

Choice C reason:

Frequent suctioning of the endotracheal tube can actually increase ICP due to the stimulation and potential for causing a cough reflex. Suctioning should be performed only as necessary and with care.

Choice D reason:

Administering a stool softener helps prevent straining during bowel movements, which can increase ICP. Ensuring regular and comfortable bowel movements is crucial in managing intracranial pressure.

Choice E reason:

Giving a 500cc NS fluid bolus can be appropriate in some clinical scenarios to maintain adequate blood pressure and perfusion. However, fluid management must be carefully balanced to avoid fluid overload, which could increase ICP. Generally, fluid boluses are not the primary method for managing ICP.

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You are caring for a patient in the ED who came in after a hard tackle in a football game. The x-rays show that he has a fracture of 2 ribs on the right side. Which intervention will the nurse expect for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a spinal cord injury at the level C3 to C4 is being cared for by the nurse in the emergency department. What is the priority nursing action?

Correct Answer is C

Explanation

A nurse is caring for a patient who has a closed-head injury with ICP readings ranging from 16-22 mm Hg. What actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply.

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

Explanation

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method to determine the effectiveness of the current treatments?

As a community health nurse, you are planning to conduct an education session on prevention strategies for spinal cord injuries. Which population would benefit most from this education?

After brain death has been determined, which of the following is a priority nursing action in caring for an organ donor?

Which assessment of a patient in shock would give the nurse the most valuable information to determine there is adequate tissue perfusion?

After a craniotomy, the nurse assesses the patient and finds generalized edema, decreased urine output, acute confusion, and muscle weakness. The client has IV fluids running at 75 mL/hr. What action should the nurse take first?

A nurse in the ED is assessing a client who is taking warfarin and experiencing rectal bleeding. Which of the following drugs should the nurse anticipate administering to the client?

A client is on mechanical ventilation and the client's spouse wonders why famotidine is needed since the client "only has lung problems." What response by the nurse is best?

A patient is brought to the emergency department after sustaining injuries in a severe car crash. The patient's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the patient is cyanotic. What action by the nurse is the priority?