Author Question: A patient is admitted to the emergency department with an open stab wound to the left chest. What is ... (Read 64 times)

Marty · **on:** Jun 25, 2018

A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take?

a. Position the patient so that the left chest is dependent.
b. Tape a nonporous dressing on three sides over the chest wound.
c. Cover the sucking chest wound firmly with an occlusive dressing.
d. Keep the head of the patient's bed at no more than 30 degrees elevation.

Question 2

The nurse is performing tuberculosis (TB) skin tests in a clinic that has many patients who have immigrated to the United States. Which question is most important for the nurse to ask before the skin test?

a. Is there any family history of TB?
b. How long have you lived in the United States?
c. Do you take any over-the-counter (OTC) medications?
d. Have you received the bacille Calmette-Gurin (BCG) vaccine for TB?

jsm54321 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: B
The dressing taped on three sides will allow air to escape when intrapleural pressure increases during expiration, but it will prevent air from moving into the pleural space during inspiration. Placing the patient on the left side or covering the chest wound with an occlusive dressing will allow trapped air in the pleural space and cause tension pneumothorax. The head of the bed should be elevated to 30 to 45 degrees to facilitate breathing.

Answer to Question 2

ANS: D
Patients who have received the BCG vaccine will have a positive Mantoux test. Another method for screening (such as a chest x-ray) will need to be used in determining whether the patient has a TB infection. The other information also may be valuable but is not as pertinent to the decision about doing TB skin testing.