Essay on Nclex Rn Questions Chapter 58

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Chapter 58
Practice Questions page 755 (652-674)

(652) 1. An emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? * Diminished breath sounds
Rationale: This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.

(653) 2. A nurse is caring for a client hospitalized with acute
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If side effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated. * * (659) 8. A nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse would expect to note which of the following? * Pain, especially with inspiration * Rationale: Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site and exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest. * * (660) 9. A client with a chest injury has suffered flail chest. A nurse assesses the client for which most distinctive sign of flail chest? * Paradoxical chest movement * Rationale: Flail chest results from multiple rib fractures. This results in a “floating” section of the ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a
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