A patient's condition has deteriorated. Changes in condition include trachea shift, absence of breath sounds on the left side, and hypotension. A chest tube was inserted on the left side with 1800 mL of blood removed
The nurse expects that the patient will be taken to surgery for a a. thoracotomy. c. splenectomy.
b. cardiac tamponade. d. pneumothorax.
A
Thoracotomy may be necessary for patients who require persistent blood transfusions or who have significant bleeding (200 mL/hr for 2 to 4 hours or more than 1500 mL on initial tube insertion) or when there are injuries to major cardiovascular structures.
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A patient's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response?
A) Perform mechanical débridement to remove the exudate and prevent further infection. B) Inform the primary care provider promptly because the graft may need to be removed. C) Perform range of motion exercises to increase perfusion to the graft site and facilitate healing. D) Document this finding as an expected phase of graft healing.
After sustaining a fall at home, a patient is brought to the emergency room exhibiting altered level of consciousness. Following a skull x-ray, the patient is diagnosed with a basilar skull fracture
Which sign should alert the nurse to this type of fracture? A) Babinski's sign B) Kernig's sign C) Battle's sign D) Brudzinski's sign
The nurse is teaching a nutrition class at the local high school. The subject for today is calcium. What is a good source of dietary calcium to teach the class?
A) Fortified orange juice B) Organ meats C) Egg yolks D) Potatoes
How will you use this information in planning your immediate assessment and care of K.B
on admission? What will be an ideal response?