Chest Trauma-ARDS NUR210

A client has been in an automobile accident, and the nurse is assessing the client for possible pneumothorax. What finding should the nurse immediately report to the HCP? 1. sudden, sharp chest pain 2. wheezing breath sounds over affected side 3. hemoptysis 4. cyanosis

1. Pneumothorax signs and symptoms include sudden, sharp chest pain, tachypnea, and tachycardia. The nurse should report these to the HCP. Other signs and symptoms include diminished or absent breath sounds over the affected lung, anxiety, and restlessness. Hemoptysis and cyanosis are not typically present with a pneumothorax

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

1, 2, 3, 4 Following a thoracentesis, the nurse should assess the client for possible complications of the procedure such as pneumothorax, tension pneumothorax, and subcutaneous emphysema, which can occur because of the needle enters the chest cavity. Pulmonary edema could occur if a large volume was aspirated causing a significant mediastinal shift. Although infection is possible complication, signs of infection will not be evident immediately after the procedure

The nurse interprets which finding as an early sing of ARDS in a client at risk? 1. elevated carbon dioxide level 2. hypoxia not responsive to oxygen therapy 3. metabolic acidosis 4. severe, unexplained electrolyte imbalance

2. A hallmark of early ARDS is refractory hypoxemia. The client's PaO2 level continues to fall, despite higher concentrations of administered oxygen. Elevated carbon dioxide and metabolic acidosis occurs late in the disorder. Severe electrolyte imbalances are not indicators of ARDS.

A client with ARDS is on a ventilator. The client's peak inspiratory pressure and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR technique for communication, the nurse calls the HCP. What recommendation should the nurse give the HCP? 1. initiating IV sedation 2. starting a high-protein diet 3. providing pain medication 4. increasing the ventilator rate

1. The client may be fighting the ventilator breaths. Sedation is indicated to improve compliance with the ventilator in an attempt to lower peak inspiratory pressures. The workload of breathing does indicate the need for increased protein calories; however, this will not correct the respiratory problem with high pressures and respiratory rate. There are no indication that the client is experiencing pain. Increasing the rate on the ventilator is not indicated with the client's increased spontaneous rate

For a client with rib fractures and a pneumothorax, the health care provider 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 breath effectively. Which finding indicates the goal has been met? 1. pain rating of 0-2 on a scale of 0-10 by the client 2. decreased client anxiety 3. respiratory rate of 26 breaths/min 4. PaO2 of 70mmHg

1. if the client reports no pain, then the objective of adequate pain relief has been met.

A client with ARDS is showing signs of increased dyspnea. The nurse reviews a report of blood gas values -ph 7.35 -PaCO2 25 mmHg -HCO3 22 mEq/L -PaO2 95 mmHg Which finding is abnormal 1. pH 2. PaCO2 3. HCO3 4. PaO2

2.

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 circulation volume

2. Blunt chest trauma may lead to respiratory failure, and maintenance of adequate oxygenation is the priority for the client. Decreasing the client's anxiety is related to maintaining effective respiration and oxygenation. Although pain is distressing to the client and can increase anxiety and decrease respiratory effectiveness, pain control is secondary to maintaining oxygenation. Maintaining adequate circulatory volume is also secondary to maintaining adequate oxygenation

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. One unit of packed red blood cells is about 250 mL. If the blood is delivered at a rate of 60 mL/h, it will take about 4 hours to infuse the entire unit. the transfusion of a single unit of PRBC should not exceed 4 hours to prevent the growth of bacteria and minimize the risk of septicemia

The nurse has placed the intubated client with ARDS in prone position for 30 minutes. Which factors would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply. 1. The family is coming in to visit 2. The client has increased secretions requiring frequent suctioning 3. The SpO2 and PO2 have decreased 4. The client is tachycardia with drop in blood pressure

3, 4, 5 the prone position is used to improve oxygenation, ventilation, and perfusion. The importance of placing clients with ARDS in prone positioning should be explained to the family. The positioning allows for mobilization of secretions, and the nurse can provide suctioning. Clinical judgment must be used to determine the length of time in the prone position. If the client's hemodynamic status, oxygenation, or skin is compromised, the client should be returned to the supine position for evaluation. Facial edema is expected with the prone position, but the skin breakdown is of concern

To promote effective airway clearance in a client with acute respiratory distress, what should the nurse do? 1. Administer oxygen every 2 hours 2. Turn the client every 4 hours 3. Administer sedative to promote rest. 4. Suction if cough is ineffective

4. The nurse should suction the client if the client is not able to cough up secretions and clear the airway. Administering oxygen will not promote airway clearance. The client should be turned every 2 hours to help move secretions; every 4 hours is not often enough. Administering sedatives to promote rest is contraindicate in acute respiratory distress because sedatives can depress respirations.

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

0.7 mL

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. How should the nurse record the breathing pattern? 1. Cheyne-Stokes respiration 2. hyperventilation 3. obstructive sleep apnea 4. Biot's respiration

1. Cheyne-Stokes respiration is defined as a regular cycle that starts with normal breaths, which increase and then decrease followed by a period of apnea.

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 HCP will "put the needle." Picture of a man sitting leaning over a table

The fluid typically localizes at the base of the thorax

A nurse should interpret which finding as a n 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

3. respiratory distress or arrest is a universal finding of a tension pneumothorax. Unilateral, diminished, or absent breath sounds is a common finding. Tracheal deviation is an inconsistent and late finding. Muffled heart sounds are suggestive of pericardial tamponade.

A client has the following ABG values: pH 7.52; PaO2 50 mmHg; PaCO2 28 mmHg; HCO3 24 mEq/L. Based upon the clients PaO2, which nursing clinical judgement should the nurse make? 1. The client is severely hypoxic 2. The oxygen level is low but poses no risk for the client 3. The client's PaO2 level is within normal range 4. The client requires oxygen therapy with very low oxygen concentrations

1. Normal PaO2 level ranges from 80 to 100 mmHg. When PaO2 falls to 50 mmHg, the nurse should be alert for signs of hypoxia and impending respiratory failure. An oxygen level this low poses a severe risk for respiratory failure. The client will require oxygenation at a concentration that maintains the PaO2 at 55-60 mmHg or more.

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

3. Fluctuation of fluid in the water seal column with respirations indicates that the system is functioning properly. If an obstruction were present in the chest tube, fluid fluctuation would be absent. Subcutaneous emphysema occurs when air pockets can be palpated beneath the client's skin around the chest tube insertion site. A leak in the system is indicated when continuous bubbling occurs in the water seal column.

The nurse is planning care for a client with a crushing chest injury. The client is in an intensive care unit, and the client's vital signs have not stabilized. Which finding puts the client at risk for ARDS? 1. history of smoking 2. low serum potassium 3. hypercapnia 4. hypovolemia

4. One of the major risk factors for development of ARDS is hypovolemic shock. Adequate fluid replacement is essential to minimize this risk. Smoking history is not directly a risk factor for ARDS. A low serum potassium level and hypercapnia are not risk factors for ARDS

A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which finding should the nurse report to the HCP? 1. arterial oxygen level of 46 mmHg 2. respirations of 12 breaths/min 3. lack of adventitious lung sounds 4. oxygen saturation of 96% on room air

1. manifestation of ARDS secondary to acute pancreatitis include respiratory distress, tachypnea, dyspnea, fever, dry cough, fine crackles heard throughout lung fields, possible confusion and agitation, and hypoxemia with arterial oxygen level below 50 mmHg. The nurse should report the arterial oxygen level of 46 mmHg to the HCP

A client with ARDS has fine crackles at lung bases, and the respirations are shallow at a rate of 28 breaths/min. The client is restless and anxious. In addition to monitoring the arterial blood gas results, what should the nurse do? Select all that apply 1. monitor serum creatinine and BUN levels 2. Administer a sedative 3. Keep the head of the bed flat 4. Administer humidified oxygen 5. Auscultate the lungs

1, 4, 5 ARDS may cause renal failure and superinfection, so the nurse should monitor using output and urine chemistries. Treatment of hypoxemia can be complicated because changes in lung tissue leave less pulmonary tissue available for gas exchange, thereby causing inadequate perfusion. Humidified oxygen may be one means of promoting oxygenation. The client has crackles in the lung bases, so the nurse should continue to assess breath sounds. Sedatives should be used with caution in clients with ARDS. the nurse should try other measures to relieve the client's restlessness and anxiety. The head of the bed should be elevated to 30 degree to promote chest expansion and prevent atelectasis

To improve the oxygenation of a client with ARDS who is receiving mechanical ventilation, the nurse should place the client in which position? 1. supine 2. semi-Fowler's 3. lateral side 4. prone

4. Prone positioning is used to improve oxygenation in clients with ARDS who are receiving mechanical ventilation. The positioning allows for recruitment of collapsed alveolar units, improvement in ventilation, reduction in shunting, mobilization of secretions, and improvement in functional reserve capacity. When the client is supine, side to side positioning should be done every 2 hours with the head of the bed elevated at least 30 degrees.