A client with a chest injury develops respiratory distress, distended jugular neck veins, and tracheal deviation. The nurse anticipates the client will receive immediate
a. chest tube insertion.
b. chest x-ray.
c. intubation.
d. needle thoracotomy.
D
These signs and symptoms are consistent with a tension pneumothorax. The immediate treatment is insertion of a large-bore IV catheter into the anterior chest wall at the second intercostal space, mid-clavicular line. A chest tube may be indicated after emergent treatment, and a chest x-ray will be ordered, but they should not delay the life-saving treatment. Intubation may be needed depending on the client's ability to ventilate and oxygenate post thoracotomy.
You might also like to view...
A young woman has been diagnosed with inflammatory bowel disease and is meeting with the nurse for health education. In an effort to manage the patient's symptoms, the nurse should recommend:
A) A high-calorie, low-residue diet B) A high-fiber, low-protein diet C) Small, frequent meals throughout the day D) A minced or pureed diet
A nurse is orienting to a new position in an infant nursery
When the healthcare provider is preparing to perform a circumcision on a 2-day-old newborn who was born 2 weeks early, the nurse asks about the administration of pain medication prior to the procedure. The healthcare provider states: "Newborns do not have pain at this age, so why should we give any medication?" The nurse's best response would be: 1. "I would think it would make the parents feel better to know it had been given." 2. "I am going to have to report you to the ethics board." 3. "Pain transmission has been documented in infants of this age." 4. "What will it hurt to just go ahead and give it?"
What is the priority nursing diagnosis for a bedridden client with a serum albumin level of 7.8 mg/dL?
A. Imbalanced Nutrition: Less than Body Requirements B. Risk for Impaired Skin Integrity C. Risk for Social Isolation D. Risk for Infection
The client is receiving 150 mL of 5.0% saline intravenously in the next 2 hours. What response should the nurse expect as a result of this therapy?
A. Increased blood pressure B. Increased dependent edema C. Increased urine concentration of potassium D. Increased hematocrit and hemoglobin levels