NCLEX book Client with chest trauma

1. pneumothorax 2. subcutaneous emphysema 3. tension pneumothorax 4. pulmonary edema

129. A client is undergoing a thoracentesis. What should the nurse monitor the client for during and immediately after the procedure? Select all that apply. 1. pneumothorax 2. subcutaneous emphysema 3. tension pneumothorax 4. pulmonary edema 5. infection

3. The chest tube system is functioning properly.

121. A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water seal chest tube drainage system. The nurse notes that the fluid in the water seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation? 1. An obstruction is present in the chest tube. 2. The client is developing subcutaneous emphysema. 3. The chest tube system is functioning properly. 4. There is a leak in the chest tube system.

4. absent breath sounds

122. Which finding would suggest pneumothorax in a trauma victim? 1. pronounced crackles 2. inspiratory wheezing 3. dullness on percussion 4. absent breath sounds

1. pain rating of 0 to 2 on a scale of 0 to 10 by the client

123. For a client with rib fractures and a pneumothorax, the healthcare provider (HCP) prescribes morphine sulfate, 1 to 2 mg/h, given IV as needed for pain. The nursing care goal is to provide adequate pain control so that the client can breathe effectively. Which finding indicates the goal has been met? 1. pain rating of 0 to 2 on a scale of 0 to 10 by the client 2. decreased client anxiety 3. respiratory rate of 26 breaths/min 4. PaO2 of 70 mm Hg (9.31 kPa)

2. 4 hours

124. A client undergoes surgery to repair lung injuries. Postoperative prescriptions include the transfusion of one unit of packed red blood cells at a rate of 60 mL/h. How long will this transfusion take to infuse? 1. 2 hours 2. 4 hours 3. 6 hours 4. 8 hours

2. fluid volume overload.

125. The primary reason for infusing blood at a rate of 60 mL/h is to help prevent: 1. emboli formation. 2. fluid volume overload. 3. red blood cell hemolysis. 4. allergic reaction.

1. sudden, sharp chest pain.

126. A client has been in an automobile accident. and the nurse is assessing the client for possible pneumothorax. The nurse should assess the client for: 1. sudden, sharp chest pain. 2. wheezing breath sounds over affected side. 3. hemoptysis. 4. cyanosis.

4. to remove air and fluid.

127. The healthcare provider (HCP) has inserted a chest tube in a client with a pneumothorax. The nurse should evaluate the effectiveness of the cheset tube: 1. for administration of oxygen. 2. to promote formation of lung scar tissue. 3. to insert antibiotics into the pleural space. 4. to remove air and fluid.

3. respiratory distress

118. A nurse should interpret which finding as an early sign of a tension pneumothorax in a client with chest trauma? 1. diminished bilateral breath sounds 2. muffled heart sounds 3. respiratory distress 4. tracheal deviation

0.67 ML

119. A nurse is to administer 10 mg of morphine sulfate to a client with three fractured ribs. The available concentration for this drug is 15 mg/mL. How many milliliters should the nurse administer? Round to one decimal point.

2. Maintain adequate oxygenation.

120. A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest from contact with the steering wheel. What should the nurse do first? 1. Reduce the client's anxiety 2. Maintain adequate oxygenation. 3. Decrease chest pain. 4. Maintain adequate circulating volume.

1. Cheyne-Stokes respiration.

130. When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, and then a couple of small breaths, then 10 to 20 seconds of no breaths. The nurse should record the breathing pattern as: 1. Cheyne-Stokes respiration. 2. hyperventilation. 3. obstructive sleep apnea. 4. Biot's respiration.

Image

The nurse is preparing the client diagnosed with pleural effusion for a left-sided thoracentesis. The x-ray shows fluid in the pleural cavity. During the preparation for the procedure, the client asks where the healthcare provider (HCP) will "put the needle." Select the appropriate site from the diagram.